Holmes Anthony D, Lee Shu Jin, Greensmith Andrew, Heggie Andrew, Meara John G
Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.
J Craniofac Surg. 2010 Mar;21(2):543-51. doi: 10.1097/SCS.0b013e3181d024b0.
Maxillonasal dysplasia, Binder type (Binder syndrome and nasomaxillary hypoplasia), is a spectrum of deficient nasomaxillary osteocartilaginous framework, deficient nasal soft tissues, and a short columella. The correction of these deformities is challenging, and results are often disappointing. Tissue expansion with multiple bone grafts for nasal augmentation from childhood has been advocated as a means to address the constricted soft tissues. However, bone grafts in children have been associated with unpredictable growth and resorption. Agreeing with the principle of serial nasal augmentation that commences in childhood, we used alloplastic material for tissue expansion followed by definitive reconstructive rhinoplasty at the completion of growth and orthognathic surgery as required. Definitive rhinoplasty mainly used a 1-piece costochondral graft cantilevered to the frontal bone.
Thirty-one patients over a period of 27 years were reviewed. The patients were divided into 2 groups based on the age of presentation, namely, prepubertal and postpubertal. The prepubertal group underwent serial tissue expansion of the constricted nasal envelope with customized silicone implants and final reconstruction by costochondral rhinoplasty at the end of puberty. The postpubertal group underwent 1-stage costochondral rhinoplasty. The definitive rhinoplasty used a cantilevered 1-piece costochondral graft retaining the dorsal periosteum that was dowelled into the frontal sinus wall.
In the prepubertal group (n = 20), 41 silicone implants were placed in the childhood years for tissue expansion of the nasal envelope. One patient developed implant infection, and another required replacement after extrusion. Long-term follow-up showed minimal resorption of the costochondral graft in the pre-expanded prepubertal group and minimal to moderate graft resorption in the postpubertal group.
Successful treatment of maxillonasal dysplasia is dependent on the following: an understanding of the underlying pathologic anatomy, namely, that of the constricted nasal tissues, serial tissue expansion of the nasal envelope in childhood, and definitive costochondral rhinoplasty at the end of growth. Early tissue expansion with the placement of alloplastic silicone implants effectively stretches the constricted nasal soft tissues in Binder syndrome to limit graft resorption after definitive nasal reconstruction with costochondral rib grafts. There is a possible role for similar tissue expansion in the postpubertal patient with alloplastic material before costochondral grafting if the soft tissues are inadequate. Long-term resorption of cantilevered, 1-piece, periosteum-covered costochondral grafts was minimal.
上颌鼻发育不全，Binder 型（Binder 综合征和鼻上颌发育不全），是一种鼻上颌骨软骨框架发育不全、鼻软组织不足和鼻中隔短小的疾病谱。矫正这些畸形具有挑战性，结果往往令人失望。有人主张从儿童期开始使用多次骨移植进行组织扩张以增加鼻体积，作为解决软组织受限的一种方法。然而，儿童期的骨移植与不可预测的生长和吸收有关。我们认同从儿童期开始进行系列鼻整形的原则，在生长完成后根据需要进行正颌手术，并使用异体材料进行组织扩张，随后进行确定性的整形鼻成形术。确定性鼻成形术主要使用一块肋软骨移植片，悬臂固定于额骨。
回顾了 27 年间的 31 例患者。根据就诊年龄将患者分为两组，即青春期前组和青春期后组。青春期前组使用定制的硅胶植入物对受限的鼻包膜进行系列组织扩张，并在青春期结束时通过肋软骨鼻成形术进行最终重建。青春期后组接受一期肋软骨鼻成形术。确定性鼻成形术使用一块保留背侧骨膜的悬臂肋软骨移植片，用销钉固定于额窦壁。
在青春期前组（n = 20），儿童期共放置了 41 个硅胶植入物用于鼻包膜的组织扩张。1 例患者发生植入物感染，另 1 例在植入物挤出后需要更换。长期随访显示，青春期前未扩张组的肋软骨移植片吸收极少，青春期后组的移植片吸收为轻度至中度。
上颌鼻发育不全的成功治疗取决于以下几点：了解潜在的病理解剖结构，即受限的鼻组织；儿童期对鼻包膜进行系列组织扩张；生长结束时进行确定性的肋软骨鼻成形术。早期使用异体硅胶植入物进行组织扩张可有效拉伸 Binder 综合征中受限的鼻软组织，以限制肋软骨移植片进行确定性鼻重建后的吸收。如果软组织不足，对于青春期后患者，在进行肋软骨移植前使用异体材料进行类似的组织扩张可能会发挥作用。保留骨膜的悬臂式单块肋软骨移植片的长期吸收极少。
