Saban Yves, Daniel Rollin K, Polselli Roberto, Trapasso Maria, Palhazi Peter
private practice in Nice, France.
Department of Plastic Surgery, University of California, Irvine School of Medicine, Irvine, CA.
Aesthet Surg J. 2018 Feb 17;38(2):117-131. doi: 10.1093/asj/sjx180.
Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author's current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author's operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (Less than 4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors' experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be "Can I keep the nasal dorsum intact?" Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a "not operated" aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty.
鼻背的处理在鼻整形手术中仍然是一项挑战。目前，大多数鼻整形术导致关键区域（K区）遭到破坏，出于美学和功能方面的原因，这需要用撑开移植物或撑开皮瓣进行重建。本文将介绍资深作者基于5年期间实施的320例临床病例，在鼻整形术中保留鼻背的当前手术技术。作者的手术技术如下：（1）鼻内入路；（2）在鼻背下区域切除一条鼻中隔条带，其形状和高度在术前确定；（3）完成外侧、横向和鼻根截骨术；（4）采用下压手术（PDO）或下拉手术（LDO）进行鼻背降低。PDO包括对完全松动的鼻锥体向下挤压，用于驼峰较小（小于4毫米）的患者。LDO包括上颌楔形切除术，用于需要降低超过4毫米的患者。共有320例患者接受了鼻背保留手术（DPO）。术后，未出现鼻背不规则或倒V畸形。在我们的44例个人修复病例中，27例患者（8.74%）曾接受过DPO，其中16例需要鼻尖修复，无需进一步的鼻背手术。其余11例患者中，主要问题是驼峰复发和/或鼻背外侧偏斜或中三分之一变宽，这需要简单的手术修复。根据作者的经验，在选定的初治患者中采用PDO/LDO是合理的。任何初次鼻整形手术前的关键问题都应该是“我能保持鼻背完整吗？”需要精确的分析和手术操作来保留鼻背骨软骨穹顶和K区。保留鼻背可使术后鼻背线条更自然，呈现出“未手术”的外观，无需进行鼻中段重建。此外，该技术操作快速简便，任何鼻整形医生都能掌握。鼻整形医生应考虑将鼻背保留技术纳入其手术方法中，而不是仅仅依赖约瑟夫鼻整形术或开放式鼻整形术。
