Saddle nuzzling: causes, symptoms, diagnosis, treatment

Defects and deformities of the nose can be divided into congenital and acquired. Among the congenital defects and deformities of the nose, the following groups are distinguished (GV Kruchinsky, 1964);

1. saddle nasal accretion of the dorsum of the nose;
2. excessively long nose;
3. excessively hunchbacked nose;
4. combination of excessive length of nose with excessive hunchback;
5. deformation of the tip of the nose.

Other authors distinguish, in addition, deformation of the septum of the nose, combined deformities of the nose, as well as a nose with a hanging tip, a wide tip, a barrel-shaped and twisted nose.

According to VM Ezrokhin (1996), all deformities of the nose of the congenital and acquired character can be divided into 5 degrees of complexity:

• I - deformation in one part of the nose (for example, distance and some lengthening of the end section);
• II - in two departments (for example, standing of the backrest + a hollow spine or lengthening of the tip of the nose);
• III - in three departments (for example, the back rest + bone-cartilage hump + elongation of the tip of the nose + curvature of the cartilaginous part of the septum to the left);
• IV and V degrees - combined deformations with localization in 4-5 departments and more.

Saddle-shaped nasal occlusion can be localized only in the bone or membranous part of the septum or simultaneously in both.

For the occlusion in the osseous part of the nose, the broad distribution of the frontal processes of the upper jaws and the flattening of the nasal bones, whose angle of attachment is approximately 170 °, is usually characterized. These bones and the membranous part of the septum of the nose are shortened. The skin in the nose region is mobile, unchanged, freely assembled into a large crease.

The occlusion of the membranous part of the septum is externally expressed in the presence of a saddle notch on its border with the bone part. This is due to the fact that the anterior margin of the cartilage of the septum of the nose has a saddle defect in this area, which also extends to the additional nasal cartilages.

Simultaneous occlusion of the osseous and membranous parts of the septum is characterized by the flattening of the nasal bones, the defect of the anterior margin of the cartilage of the septum of the nose, and the depression of both additional nasal cartilages, which is manifested by a sharp tip of the nose, which depresses the patient.

In addition to cosmetic deficiencies with nasal deformities, there may be a violation of smell, difficulty in nasal breathing, nosebleeds, hearing impairment, headache, increased mental and physical fatigue. Many patients with deformities of the nose because of their appearance avoid communication, change work or completely leave it.

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Treatment of congenital saddle nuzzling of the nose

When determining the indications for nose correction and choosing its method, it is necessary to consider whether the planned shape of the nose corresponds to the entire appearance of the patient. For example, a nose with an absolutely straight back and a broken tip looks ugly, because in this case the face becomes simpler and loses its individuality; With a rounded face shape, a wide, truncated nose harmonizes; with a sloping forehead and microgenia (retrognathia), even a small nose seems excessively large. A woman with a Russian type of face comes up with a slightly raised, upturned tip of the nose, and a man with a nose with a slight hump that gives the person a special expression, masculinity.

It should also be taken into account that in 6-8 months after the operation, there will be (during the scarring) some deformation of the tissues of the tip of the nose and it will slightly drop, apotom in some cases it is expedient to "hypercorrection".

The correction of the nose in girls is recommended to be performed no earlier than 18 years, i.e. After the end of the development of the facial part of the skull, and in men - not earlier than 21-23 years. At the age of more than 40 years, it is not advisable to perform correction of the nose, as patients are hard at getting used to their changed appearance, and sometimes even regret this change.

Treatment of nasal accentuation is usually carried out mainly by the introduction of allochondria, teflon or silicone. The most ideal material is autochondria or allochondrices, properly preserved, for example, by lyophilization. With the use of lyophilized cartilage, complications such as his suppuration after surgery, exposure of the graft or necrosis of the nasal backbone, because of his insufficient preoperative rehydration, were very rarely observed.

Apply plastic masses should be only in extreme cases, when it is impossible to obtain allohrchash or the patient refuses to "wear cadaveric material." If, therefore, the surgeon is forced to use plastic, then he should choose silicone rubber (polydimethylsiloxane), OD Nemsalze (1991) reported very highly on the results.

Elimination of the defect of the wing of the nose and the adjoining part can be achieved due to the stem with its epithelization by the submerged cutaneous locus by O. P. Chudakov (1971-1976), which AI Pantyukhin and co-workers. (1992) cut out on the frontal or scalp.

The procedure of the operation (according to GI Pakovich)

After anesthetizing the tissues with an anesthetic solution, a "bird" section is made (according to AE Rauer). To prevent the formation of a postoperative retracted scar, the lower edge of the skin in the wound area should be cut off by 1-1.5 mm. The skin in the tip and back of the nose is removed to a depth of 1.5 cm first with a scalpel, and then with a not very sharp narrow rasp or Cooper scissors. At the same time, one should strive to advance in one layer and separate the skin "with a reserve": somewhat wider than the implantable cartilage, and with a sufficient amount of subcutaneous fat, so that the outline of the cartilaginous graft is not visible under the skin.

In cases when the thin layer of tissue is being cut off, the skin above the cartilage will initially be pale, and then cyanotic due to insufficient circulation of blood.

The cartilage seedling is cut from the costal cartilage on a wooden sterile plate (for rest). Given that the cross-section of the rib is oval, the position of the cartilage to be treated must be different, depending on the shape of the insert.

To facilitate the modeling of the required shape of the transplant, GI Pakovich recommends young doctors to use a pre-prepared wax template that beforehand is interfered with in 95% alcohol for 25-30 minutes, then dried, treated with an antibiotic solution and stored on a sterile table.

If there is no template, before the beginning of the operation, measure the length of saddle accretion with a sterile rod on which a notch is made. This technique relieves the surgeon of the need to apply a piece of processed cartilage to the surface of the nose to determine the length and shape of the transplant, and reduces the threat of infection.

By creating the liner of the desired shape, a gauze swab is removed from the wound and a graft is inserted into the subcutaneous pocket.

If the occlusion of the osseous part of the septum is inconspicuous, cut the periosteum above the nasal bones, peel it with a rasher, forming a pocket, and insert the upper pointed end of the liner, so that it is well fixed in the wound.

If the saddle-shaped occlusion of the osseous part of the nasal septum is very sharply expressed, it is not possible to raise the small periosteum to the required height and bring the end of the liner under it. In such cases, its end is placed on top of the periosteum.

When eliminating the occlusion in the membranous part of the septum, it should be borne in mind that the slightest inaccuracy in the fit of the liner will be manifested by the unevenness of the back of the nose immediately after the disappearance of the postoperative edema. If the liner is more than necessary, its upper end is superimposed on the lower edge of the nasal bones and forms a prominent protrusion. If the insert is smaller than necessary, the nasal bones rise above it. Therefore, GI Pakovich recommends the creation of a spine and a ledge in the region of the upper end of the transplanted cartilage, so that a small blind pocket is formed under the anterior edge of the nasal bones. To do this, first cut the scalpel portion of the cartilage of the septum of the nose, cut the periosteum in the transverse direction and flake it with a rasp. As a result, the thorn of the insert enters the lower edge of the nasal bones, located on the exfoliated periosteum and sometimes reaches the lower edge of the osseous part of the septum; In the groove of the liner, the anterior edge of the cartilage of the septum of the nose is attached with additional nasal cartilages attached to it. The lower part of the liner is closely attached to the upper edges of the lateral legs of large cartilages of the wings of the nose, and the lower edge of the nasal bones forms a butt joint in the form of a lock with the liner.

When eliminating the ossification of the osseous and the membranes of the septum of the nose, it is first necessary to produce a longer and thinner cartilaginous insert, which, unfortunately, is difficult to incise, since it is possible to cut it. Therefore, such a narrow liner is better to take from the central part of a piece of cartilage, equally remote from the perichondrium. As a result, the tension force of the individual cartilaginous fibers of the liner will be the same on all sides, and therefore there will be no deformation after the operation. Secondly, it should be borne in mind that with saddle-shaped occlusions of the back of the nose, congenital underdevelopment of the cartilage of the septum of the nose in the antero-lower section is also often observed. Therefore, the liner, placed under such a deformation under the skin of the dorsum of the nose, rests only on the nasal bones from below in the form of a cartilage of the septum of the nose and is lowered due to the lack of support. This is promoted by the pressure of the skin in the region of the membranous part of the septum of the nose, especially its tip, where the skin is thick and elastic. As a result of lowering the lower end of the liner, its upper end rises, tears the periosteum and visibly protrudes above the surface of the dorsum of the nose. Therefore, the lower end of the liner needs to create a support in the form of a rafter of a rectangular piece of cartilage 2.5-3 mm in thickness, its length should correspond to the height of the absent cartilage of the septum of the nose, i.e., the distance from the nasal crest of the upper jaw to the transition of the medial legs of the large cartilages of the wings of the nose lateral. At the end of the sawmill, facing the forward nasal awn, create a channel for the abutment in the bone (B) depth of 4-5 mm. That it be fixed tightly and not slip.

At the end of the rafter, facing the tip of the nose, create a square spike, on the sides of which there are protrusions (hangers). Correspondingly, the size of the section of this stud is made with an opening at the lower end of the cartilage liner prepared to eliminate the nasal occlusion of the back of the nose. Thus, two cartilaginous liners are articulated.

To determine the height of the sawmill and place it on the right place, the AE Rauer cut at the tip of the nose continues down the septum of the nose to the lower lip. Stratify the skin of the septum to the nasal crest, measure (the steel ruler or linear tool) the height of the necessary rafter and begin to model it. Then put it between the right and left parts of the split skin of the septum, check the stability and connect, as mentioned above, to the end of the main liner.

If the spike on the rafter is longer than necessary, and protrudes above the surface of the hole in the main liner, the end of it is cut to the level of the upper surface of the main liner.

The lower end of the main liner can be given any shape, corresponding to the desired shape of the tip of the nose.

If the large cartilages of the wings of the nose are normal and the tip of the nose has the correct shape (against the backdrop of the nose of the nose and in the absence of the membranous part of the nasal septum), the end of the liner can be modeled narrow and placed in the groove between the large cartilages of the wings of the nose.

If the tip of the nose is wide and flattened, you can (before inserting the liner) cut off the cartilage of the wings of the nose at the place of transition to the medial legs, and then sew them over the liner. As a result, the tip of the nose will rise and become round.

Finally, when the large cartilages of the wings of the nose are poorly developed or sharply deformed, the terminal section of the main liner should be made thick and round, which will provide the necessary shape of the nose.

After the introduction of the cartilaginous liner previously pretreated with 5% alcohol solution of iodine, seams are placed along the incision line, both lower nasal passages are padded for 1-2 days (to avoid the formation of a hematoma), and a collodion bandage is applied on the nose, which is also suitable for other cosmetic operations. To make bandages, square gauze napkins (15x15 cm) are folded in 4-8 layers and carefully smoothed. To ensure that both halves of the bandage are symmetrical in shape, the layers of gauze are bent along the middle line. From the folded halves of gauze pieces cut out with a scissors figure, somewhat resembling the profile of the hat. After the deployment of the gauze, a butterfly-shaped bandage is obtained (B), in it two cheek divisions, the frontal and the tip of the nose are distinguished. The cut layers of gauze are dropped into a glass with collodion and lightly squeezed, then applied to the dry surface of the skin of the nose and cheeks. Fingers give the bandage a nose shape, reproducing its relief (B). In this case, squeeze the remaining blood in the wound, the drops of which seep between the sutures.

This bandage hardens after 5-8 minutes, is stiff enough to hold the cartilage graft in its prescribed position and prevent the formation of a hematoma. In addition, it provides an aseptic condition of the underlying skin, does not cover the eyes, does not interfere with the intake of food and toilet face.

Remove the collodion bandage 6-10 days after the operation, having saturated it with ether or alcohol (in that it is easier for the patient to bear). Removal of the dressing is facilitated by the accumulation under it of sebaceous and sweat glands of the nose and cheeks.

The endonasal method of introducing the allochondrium liner

The endonasal method of introducing the allochondrium liner from cosmetic considerations is more effective than extranasal. It is shown with the westernisation of the back of the nose above the large cartilages of the wings of the nose. If the saddle is located below, it is not advisable to use the endonasal method of surgery, since after it, as a rule, scar scar deformation of the nose wing occurs.

Procedure (by G. I. Pakovich): a cut (length 1.5-2 cm) of the mucosa in the transverse direction at the boundary between the indicated cartilages; small, curved blunt-ended scissors exfoliate the skin over the additional nasal cartilage, and then in the zone of the occlusion of the back of the nose, the tip and in the region of the wings of the nose. If the zone of the cut off skin is slightly longer and wider than the graft area, this will allow it to be set in the correct position.

In cases where the lower edge of the saddle is located below the incision of the mucosa, the skin detachment should be made even higher so that the graft can be completely inserted under the skin above the incision. Only after the lower end of the transplant has passed the incision of the mucous membrane, by reverse movement, bypassing the incision, place it in the fouled area.

The upper end of the cartilaginous insert is inserted under the periosteum of the nasal bones, as in operations with an external incision.

The edges of the wound on the nasal mucosa are sewn with catgut, the nasal passages are covered with gauze strips for 2-3 days. Outside, a fixing collodion bandage is applied

When correcting defects in the back of the nose with plastic liners, monolithic explants should be avoided, as this often leads to stagnation in the implant-covering skin (it becomes bluish, especially when the ambient temperature decreases). It is often observed the sequestration of such liners, especially after accidental nasal trauma.

The data of experimental studies and clinical observations show that the best material for explantation is the frame explants from Teflon mesh 0.6-0.8 mm thick. The outer cut along the Rauer with the introduction of such an explant is required only when it reaches a large size; with pronounced curvatures and combined deformities of the nose make the external and endonasal (between the wing and triangular cartilage) incisions with a sharp eye scalpel.

The lower nasal incision or inner margin along the wing of the nose is produced when the membranes of the membranous and osseous-membranous parts of the septum of the nose develop, and also with certain deformations of the nose wing.

Treatment of congenital deformities and nonsense of the tip of the nose (according to GI Pakovich)

Deformations of the tip of the nose can be in the form of a thickening of the tip of the nose, the sagging of the septum of the nose or changes in its shape.