RU2748125C1 - Method for eliminating limited nose defect - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to maxillofacial surgery. An incision is made in the soft tissues of the recipient zone. A receiving bed is formed in the recipient zone of a limited nasal defect using soft tissue mobilization. A soft tissue incision is made along the upper edge of the nasolabial fold. Then, a tunnel is formed in the subcutaneous muscle layer from the columella area into the oral cavity to the projection of the facial arteries and veins. A revascularized skin autograft is obtained on retrograde blood flow 3.5-5.5 cm long, 2.5-4.0 cm wide, 0.5-1.5 cm thick from the periauricular region by a linear incision along the pre-auricular fold to the temporal region. The autograft is carried out through the previously formed tunnel and revascularized by stitching the frontal or parietal branch of the superficial temporal artery with the facial artery and the superficial temporal vein with the facial vein in an end-to-end manner intraorally. The autograft is fixed to the receiving bed.

EFFECT: allows to eliminate a limited defect of the nose using anatomically and physiologically similar tissue, avoid scar and necrotic changes in soft tissues, infection, reduce the invasiveness of the intervention and the likelihood of complications from the donor area, increase the aesthetic effect.

1 cl, 2 ex, 5 dwg

Description

This invention relates to medicine, namely to maxillofacial surgery, and can be used to eliminate limited defects in the nose, which may result from congenital malformations, traumatic injuries, tumor-like formations.

A known method for eliminating a limited defect of the nose using a paramedial flap from the forehead.

The method consists in the rotation of the paramedial flap from the forehead after preliminary marking on the prepared bed of the recipient zone of the limited nasal defect.

A preliminary marking of the paramedial flap from the forehead is carried out, in accordance with the size of the limited nasal defect. The paramedial flap is nourished by the axial type of blood supply from the supra-block artery. Determine the "turning point" to ensure sufficient flap length, and rotate to the area of the limited nasal defect. The donor area is sutured with local tissues. [A.A. Kulakov, T.G. Robustova, A.I. Nerobeev Surgical dentistry and maxillofacial surgery. - GEOTAR-Media. - 2015. - S. 636-657].

The disadvantage of this method is the high probability of flap necrosis due to the angle of flap rotation.

There are also problems with the closure of the donor defect, leaving a visible scar.

A significant disadvantage of this method is that the operation takes place in 2 stages. 3 months after the complete engraftment of the paramedial flap, it is necessary to cut off the feeding pedicle from the forehead.

The closest to the proposed method is a method for eliminating a limited nasal defect with a revascularized axial skin-fascial radiation autograft. [E.V. Verbo, A.I. Nerobeev; Reconstruction of the face with revascularized autografts - M .: JSC "Medicine" Publishing House, - 2008. - S. 138-153].

The method consists in forming a receptive bed in the recipient zone of a limited nasal defect by mobilizing the soft tissues of the nose, collecting and moving an axial fascial skin radial autograft, revascularizing it with facial vessels in the area of the nasolabial fold, followed by fixing it to the receiving bed in the area of a limited nose.

The axial fascial skin radial autograft is taken by a linear incision of the skin, subcutaneous fat, superficial fascia of the flexor surface of the forearm, followed by the separation of the axial fascial skin radial autograft from the underlying tissues from which the vascular pedicle is isolated - the radial artery and vein, to the place of confluence them into the brachial artery and vein. The distal and proximal ends of the vascular pedicle are alloyed.

In accordance with the size of the limited defect of the nose, an axial skin-fascial radial autograft is formed, revascularized by stitching the vascular pedicle - the radial artery and vein with the facial artery and vein, fixed with interrupted sutures in the area of the limited defect of the nose edge to edge.

Split skin from the thigh is used to close the donor defect. [E.V. Verbo, A.I. Nerobeev; Reconstruction of the face with revascularized autografts - M: JSC "Medicine" Publishing House, - 2008. - P. 46-50].

The disadvantages of this method is the large thickness of the revascularized axial skin-fascial radiation autograft, in comparison with the recipient zone, the color of the flap differs from the color of the surrounding tissues, which is aesthetically unsatisfactory.

Often there is ischemia of the upper limb against the background of the development of radial artery dysfunction, the impossibility of closing the donor defect with local tissues, the need to use a free split skin autograft to close the defect in the donor zone.

The technical result of this invention is to increase the functional and aesthetic effect, reduce trauma.

The technical result is achieved by the fact that in a method for eliminating a limited nasal defect by making an incision in the soft tissues of the recipient zone and forming a receiving bed in the recipient zone of a limited nasal defect using soft tissue mobilization and closing the defect with a revascularized autograft with its subsequent fixation to the receiving bed, a distinctive feature is that that additionally an incision is made from the upper edge of the nasolabial fold, followed by the formation of a tunnel in the subcutaneous muscle layer from the columella area into the oral cavity to the projection of the facial artery and vein, and a revascularized skin autograft is used as a revascularized autograft on retrograde blood flow 3.5-5 , 5 cm, 2.5-4.0 cm wide, 0.5-1.5 cm thick, obtained from the periauricular region by a linear incision along the preauricular fold to the temporal region, carried out through a previously formed tunnel and revascularized p by stitching the frontal or parietal branch of the superficial temporal artery with the facial artery and the superficial temporal vein with the facial vein in an end-to-end manner intraorally, followed by fixing it to the receiving bed. The method is carried out as follows (Fig. 1-5):

Before the operation, multispiral computed tomography (MSCT) with angiography is performed to assess the state of the superficial temporal artery (PVA) (1) and its branches (frontal and parietal) and superficial temporal vein (PVV) (2).

The size of the revascularized skin autograft (3) from the periauricular region (4) required for collection is determined to close the limited nasal defect (5).

The receiving bed (6) is prepared by incision of the skin (7) and subcutaneous fat of the recipient zone and with mobilization of the soft tissues of the recipient zone of the limited nasal defect (5). In the area of the upper edge of the nasolabial fold (8), an incision is made in the skin, subcutaneous fat (SAD) and a tunnel (9) is formed in the subcutaneous layer for the vascular pedicle (10) of a skin autograft (3) from the periauricular region (4), which lead out into the oral cavity through the buccal mucosa (11), where the facial artery (12) and vein (13) are highlighted, which are taken on a holder, to form anastomoses.

After preliminary hydro-preparation of the soft tissues of the periauricular region (4) from the preauricular fold (14) to the temporal region (15), a linear incision of the skin and subcutaneous fat is performed along the scalp along the temporal superficial artery (1). Layer-by-layer tissue dissection is performed, the surface plate of the temporal fascia is dissected. The superficial temporal artery (1) and the superficial temporal vein (2) are isolated. Moving up, they reach the bifurcation (PVA) (16) on the frontal (17) and parietal (18) branches. A vascular pedicle (10) is isolated, including the frontal (17) or parietal (18) branch of the superficial temporal artery (1) and the superficial temporal vein (2), which are taken on a holder. Allocate the skin area from the periauricular region (4) 3.5-5.5 cm long, 2.5-4.0 cm wide, 0.5-1.5 cm thick.Alloy PVA (1) and PVV (2) at the base of the pedicle (10) in the parotid salivary gland. A skin autograft (3) is taken from the vascular pedicle (10) from the periauricular region (4).

The vascular pedicle (10) of the skin autograft (3) is passed through a previously formed tunnel (9) in the subcutaneous layer, where anastomoses are formed with recipient vessels (facial artery (12) and facial vein (13)) intraorally.

Revascularization of a skin autograft (3) on retrograde blood flow from the periauricular region (4) is performed using microsurgical techniques with the formation of anastomoses: the facial artery (12) from one of the branches (frontal (17) or parietal (18)) of the superficial temporal artery (1) and a facial vein (13) with a superficial temporal vein (2) of an end-to-end autograft (3) intraorally.

The vascular pedicle (12) maintains its longitudinal direction in retrograde blood flow without torsion and bending.

The revascularized skin autograft (3) is adapted and fixed in retrograde blood flow from the periauricular region (4) to the defect area (5) with interrupted sutures.

Hemostasis is performed using bipolar electrocoagulation during the operation.

Example 1.

The patient, T., was in the department of reconstructive maxillofacial surgery with a diagnosis of "Post-traumatic nose defect. Cicatricial deformity. Condition after trauma."

From the anamnesis: The patient was injured in 2019. The first surgical treatment in the ChLh department at the place of residence.

The patient was consulted in the department about the possibility of carrying out reconstructive surgery in the amount of elimination of a limited nasal defect using a revascularized skin autograft in retrograde blood flow from the periauricular region.

In the clinic, after a complete clinical and laboratory examination under conditions of endotracheal anesthesia, the operation was performed using the proposed method.

The receiving bed was prepared by incision of the skin, subcutaneous fat of the recipient zone and mobilization of the soft tissues of the recipient zone of the limited nasal defect.

In the area of the upper edge of the nasolabial fold, an incision was made in the skin, PZhK and a tunnel was formed in the subcutaneous muscle layer for the vascular pedicle of the skin autograft from the periauricular region, which was brought out into the oral cavity through the buccal mucosa, where the facial artery was isolated and taken on a holder under the buccal muscle and the facial vein and prepared for the formation of end-to-end anastomoses intraorally.

After preliminary hydropreparation of the soft tissues of the periauricular region and marking on the right along the preauricular fold to the temporal region along the scalp along the temporal artery, a linear incision of the skin and subcutaneous fat was made. Next, a layer-by-layer tissue dissection was performed, the superficial plate of the temporal fascia was dissected. Under the superficial plate of the temporal fascia, the superficial temporal artery (PVA) and superficial temporal vein (PVV) feeding the skin area were visualized. Moving up, we reached the bifurcation (PVA) on the frontal and parietal branches. A vascular pedicle was isolated, including the frontal branch of the superficial temporal artery and the superficial temporal vein, which were taken on a holder.

A skin area was cut out from the periauricular area, measuring 5.5 × 2.5 × 1.5 cm.

The dissection was continued between the superficial temporal artery and the superficial temporal vein towards the base of the vascular pedicle, which were located in the thickness of the parotid salivary gland. At the base of the vascular pedicle, the superficial temporal artery and vein were ligated, and the autograft was excised.

Thus, a skin autograft on a vascular pedicle was obtained, containing subcutaneous fat and skin from the periauricular region.

Hemostasis was performed using bipolar electrocautery during the operation.

The vascular pedicle was passed through a previously formed tunnel in the subcutaneous muscle layer in the region of the upper edge of the nasolabial fold, where anastomoses were formed with recipient vessels (facial artery and vein) intraorally.

Revascularization of the skin autograft was performed using microsurgical techniques with the formation of anastomoses: the facial artery with the frontal branch of the superficial temporal artery and the facial vein with the superficial temporal vein of the autograft in the end-to-end manner.

The vascular pedicle in retrograde blood flow, without twisting and kinking, retained its longitudinal direction.

The skin revascularized autograft was adapted and fixed in retrograde blood flow from the periauricular region to the defect area with interrupted sutures.

Hemostasis was performed using bipolar electrocautery during the operation.

In the postoperative period, infusion, antibacterial, anti-inflammatory, antiplatelet, antihistamine, analgesic therapy, dressings were performed.

As a result of the operation performed according to the proposed method, a limited defect of the nose was eliminated.

Example 2.

The patient, K., was in the department of reconstructive maxillofacial surgery with a diagnosis: "Post-traumatic defect of the terminal section of the nose."

From the anamnesis: The patient received a household trauma to the face in 2017. The first surgical treatment in the department of maxillary surgery at the place of residence. A defect in the tip of the nose has been formed.

She was consulted in the department about the possibility of carrying out reconstructive surgery in the amount of eliminating a limited nasal defect using a revascularized skin autograft in retrograde blood flow from the periauricular region.

In the clinic, after a complete clinical and laboratory examination under conditions of endotracheal anesthesia, the operation was performed using the proposed method.

The receiving bed was prepared by incision of the skin and subcutaneous fat of the recipient zone and with mobilization of the soft tissues of the recipient zone of the limited nasal defect.

In the area of the upper edge of the nasolabial fold, an incision was made in the skin, PZhK and a tunnel was formed in the subcutaneous muscle layer for the vascular pedicle of the skin autograft from the periauricular region, which was brought into the oral cavity through the buccal mucosa, where it was isolated, and the facial artery was taken on a holder under the buccal muscle and the facial vein, and prepared for end-to-end anastomoses intraorally.

After preliminary hydropreparation of the soft tissues of the periauricular region and marking on the left along the preauricular fold to the temporal region along the scalp along the temporal artery, a linear incision of the skin and subcutaneous fat was made. Next, a layer-by-layer tissue dissection was performed, the superficial plate of the temporal fascia was dissected. Under the superficial plate of the temporal fascia, the superficial temporal artery (PVA) and superficial temporal vein (PVV) feeding the skin area were visualized. Moving up, we reached the bifurcation (PVA) on the frontal and parietal branches. A vascular pedicle was isolated, including the parietal branch of the superficial temporal artery and the superficial temporal vein, which were taken with a holder.

A skin area was cut out from the periauricular area, 3.5 × 4.0 × 0.5 cm in size.

The dissection was continued between the superficial temporal artery and the superficial temporal vein towards the base of the vascular pedicle, which were located in the thickness of the parotid salivary gland. At the base of the vascular pedicle, the superficial temporal artery and vein were doped, and the autograft was excised.

Thus, a skin autograft on a vascular pedicle was obtained, containing subcutaneous fat and skin from the periauricular region.

Hemostasis was performed using bipolar electrocautery during the operation.

The vascular pedicle was passed through a previously formed tunnel in the subcutaneous muscle layer in the region of the upper edge of the nasolabial fold, where anastomoses were formed with recipient vessels (facial artery and vein) intraorally.

Revascularization of the skin autograft was carried out using microsurgical techniques with the formation of anastomoses: the facial artery with the parietal branch of the superficial temporal artery and the facial vein with the superficial temporal vein of the autograft by the end-to-end type.

The vascular pedicle in retrograde blood flow, without twisting and kinking, retained its longitudinal direction.

The skin revascularized autograft was adapted and fixed in retrograde blood flow from the periauricular region to the defect area with interrupted sutures.

Hemostasis was performed using bipolar electrocautery during the operation.

In the postoperative period, infusion, antibacterial, anti-inflammatory, antiplatelet, antihistamine, analgesic therapy, dressings were performed.

As a result of the operation performed according to the proposed method, a limited defect of the nose was eliminated.

Thus, the proposed method can be used to eliminate limited defects of the nose resulting from congenital malformations, severe atrophy, traumatic injuries, resections for tumor-like formations.

The proposed method has a number of advantages, such as: the possibility of eliminating a limited nasal defect using anatomically and physiologically similar tissue - a revascularized skin autograft from the periauricular region, the skin area of which is fed by retrograde blood flow, which does not depend on the blood supply to the receiving bed, which avoids scar and necrotic changes in soft tissues, infections.

The anatomical proximity of the donor area to the recipient area allows creating an optimally smooth and even surface without creating an excess of replanted tissues, and the tissue of the revascularized skin autograft to provide this area with sufficient blood supply, thereby ensuring the safety and reliability of this method.

Also, this method has the advantage that it is aesthetically suitable option for the patient, since the scars are located in the preauricular fold, which makes them almost invisible, the anastomoses are formed intraorally.

Possibility of eliminating limited defects of the nose with relatively little donor damage, which reduces the invasiveness of the intervention and the likelihood of complications from the donor area.

Claims (1)

A method for eliminating a limited nasal defect by making an incision in the soft tissues of the recipient zone and forming a receiving bed in the recipient zone of a limited nasal defect using soft tissue mobilization and closing the defect with a revascularized autograft, followed by fixing it to the receiving bed, characterized in that additionally, a soft tissue incision is made according to the upper edge of the nasolabial fold, followed by the formation of a tunnel in the subcutaneous muscle layer from the columella area into the oral cavity to the projection of the facial artery and vein, and a revascularized skin autograft is used as a revascularized autograft on retrograde blood flow 3.5-5.5 cm long, 2 cm wide , 5-4.0 cm, 0.5-1.5 cm thick, obtained from the periauricular region by a linear incision along the preauricular fold to the temporal region, carried out through a previously formed tunnel and revascularized by suturing the frontal or parietal branch of the superficial the temporal artery with the facial artery and the superficial temporal vein with the facial vein in the "end-to-end" type intraoral with its subsequent fixation to the receiving bed.

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