Even with the open technique, despite direct vision, it can sometimes be difficult to separate scar tissue from cartilage tissue.
The situation that patients often want to improve in secondary surgeries; These are complaints of nasal congestion that developed after previous surgeries or existed but did not go away after surgery. In this group of patients, excessive reduction, collapse and weakening of the nasal support mechanisms may have occurred due to previous surgical interventions. The most important causes of postoperative obstruction are; It is the collapse of the side wall of the nose, collapse in the middle dome area, and inadequate correction of the middle compartment curvature.
Certain cosmetic disorders seen from the outside often indicate and accompany the disorder inside. Narrow middle dome area, inverted V deformity at the bone-cartilage junction of the nasal dorsum, and "pinch deformity" in the nasal dorsum and side wall cartilages, which gives the appearance of being pinched with two fingers, can be counted among these. Avoiding taking more than necessary side cartilages of the tip of the nose (lower lateral), strengthening the alar base and tip (base and tip of the nose) area, and reconstructing the middle dome area are the key approaches required to avoid the negative consequences mentioned above.
Secondary. The most important difficulty of surgery is that the septal cartilage (middle part of the nose cartilage) is not sufficient to take pieces. In midsection surgeries, sometimes it may be necessary to leave only the amount of cartilage that must remain there in the first surgeries (L-strut). In such cases, cartilage pieces must be taken from other areas. These areas are ear or rib cartilage. A piece of cartilage is taken from the ear canal through an incision made behind or in front of the ear. However, the cartilage taken from the ear is both limited in quantity and sometimes unsuitable in terms of shape. In these cases, rib cartilage is a good option. Rib cartilage is sufficient in quantity and can be shaped as desired. Rib cartilage is taken from the cartilage part of the 7th, 8th and 9th ribs. It is removed by making a 3-5 cm incision in the skin over the rib to be removed. It is taken from the ribs on the right side. Rib cartilage is cut to the desired size, thinness and shape using various techniques and It is used according to the purpose.
Problem areas in secondary surgeries are generally the nasal tip (nasal tip), upper nasal cartilages and the middle vault region of the nasal dorsum. If the nasal base is not adequately supported during the initial surgery, weakness may occur at the tip of the nose. This condition may manifest itself as a drop in the tip of the nose, a decrease in the angle between the nose and the upper lip, where the projection of the tip of the nose is low. In some cases, it may occur as a result of the removal of a piece from the anterior end of the middle compartment and retractions caused by scarring on the side cartilages of the nose tip and the tip of the nose lifting more than normal. In these cases, the corrective technique is planned according to the condition of the remaining cartilages. Generally, the lower side cartilages of the nasal tip are found to be weakened and have lost their tension. In cases where the lower end of the middle section of the nose has been shortened too much in previous surgeries, it is possible to strengthen the nasal base and eliminate the drooping nose tip by placing extension grafts (pieces) in this area. In cases of more severe nasal tip ptosis, the droopiness can be eliminated and the projection can be increased by placing columellar strut (a graft that functions as a kind of pole placed between the cartilages at the very end of the middle compartment) with pieces taken from the rib cartilage. are the size, shape and positions of the intermediate and medial legs of the lateral cartilage. Asymmetries, pits, bulbosity and other deformities may occur due to previous surgery. Often the cartilages are damaged and the reshaped cartilages lack support for the tip of the nose. In patients with thick skin, a strong nasal tip skeleton should be created so that its reflection on the skin through the soft tissue can be clear. In this case, a shield graft suitable for the desired augmentation and shape can be used. By softening the transition between the two grafts with a cap or butress graft placed on the upper end border of the shield graft, the desired shape can be achieved in the angle between the tip of the nose and the back of the nose. A lateral crural graft can be placed on the cartilage section that forms the side wall of the lower tip of the nose, if there is weakness, collapse or depression.
The tip of the nose. Excessive removal of cartilage from the side wall in previous surgeries is one of the main reasons for stenosis and collapse in this section. This complication is more common in patients with long, narrow noses and those with a previously protruding supraalar area. This may manifest itself as a collapse in the side wings of the nose when taking deep breaths. Alar batten graft is used to correct this situation. This negativity is eliminated by placing the piece in the area where the most weakness and collapse occurs on the side wall. This piece may sometimes need to be stitched to the lateral cartilage in order to prevent it from negatively affecting the width of the nostril and slipping out of place. Depending on the shape and amount of weakness in the side wall of the nasal tip, this graft (piece) is placed and fixed in the appropriate position and shape. Intranasal stents (nostril-shaped devices of various sizes, made of soft material) used while lying down in the evening can be used for various periods of time to prevent the side wall of the nasal tip from approaching the midline again and creating stenosis in the postoperative period. In adverse situations related to the lower border of the side wall, it may occur due to excessive removal or weakening of the cartilages. Excessive cephalic trimming (removing a piece from the upper part of the lateral cartilage of the tip of the nose) may cause recession at the alar rim border or increase the side visibility of the middle section of the nose (columellar show). Again, the weakening of this area may cause notching, collapse, and distortion of the triangular structure of the nose seen from below. The grafts placed on the border of the alar rim are narrow pieces of 2-3×5-8 mm cartilage. They are placed in the created pocket. If necessary, they are fixed to the shield graft or soft tissue with stitches. This contributes to the triangular appearance when viewed from below. In severe alar retractions, lengthening can be achieved in the alar rim region with composite grafts (consisting of cartilage and skin).
Collapse in the lower end of the upper lateral cartilage and internal valve, nasal dorsum that looks like it is squeezed with two fingers (pinched nose), inverted V The deformity occurs as a result of the deterioration of the stability of the horizontal part of the middle dome. Spread as in primary surgeries Placing individual grafts is the most suitable option to ensure symmetry and support of the middle dome in secondary surgeries. However, in secondary surgeries, the inserted part may need to be larger and more numerous.
Asymmetry and irregularities due to the previous surgery may be observed in the bone dome section. These generally occur due to uneven osteotomy and inadequate repositioning. If the hump on the back of the nose is flattened without lateral osteotomies and approximation to the midline, an "open roof" deformity may occur. These negativities are solved by repeating osteotomies and placing the bones in their new positions. If there are irregularities on the back of the nose, these irregularities are corrected. If the nasal dorsum is too low, an attempt is made to raise it by placing a graft (piece) in this area and the radix area. Correcting narrowed nasal bones is a bit more difficult. In this case, osteotomies are performed again and the bone structures are removed from the midline and intranasal stents (apparatus) are used to prevent them from coming back to the midline.
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