Saddle nose: causes, symptoms, diagnosis, treatment

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

1. saddle-shaped retraction of the nasal bridge;
2. excessively long nose;
3. excessively humped nose;
4. a combination of excessive length of the nose and its excessive hump;
5. deformations of the tip of the nose.

Other authors also distinguish between deformation of the nasal septum, combined deformations of the nose, as well as a nose with a drooping tip, a wide tip, a barrel-shaped and crooked nose.

According to V. M. Ezrokhin (1996), all nasal deformities of congenital and acquired nature can be divided into 5 degrees of complexity:

• I - deformation in one section of the nose (for example, protrusion and some lengthening of the terminal section);
• II - in two sections (for example, protrusion of the back + gentle hump or elongation of the tip of the nose);
• III - in three sections (for example, protrusion of the back + bony-cartilaginous 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 localized in 4-5 sections or more.

Saddle-shaped depression of the nasal bridge can be localized only in the bony or membranous part of the septum or simultaneously in both.

The recession in the bony part of the nose is usually characterized by a wide arrangement of the frontal processes of the upper jaws and flattening of the nasal bones, the angle of connection of which is approximately 170°. These bones and the membranous part of the nasal septum are shortened. The skin in the area of the bridge of the nose is mobile, unchanged, and freely gathers into a large fold.

The recession of the membranous part of the nasal septum is externally expressed by the presence of a saddle-shaped notch on its border with the bony part. This is explained by the fact that the anterior edge of the cartilage of the nasal septum has a saddle-shaped defect in this area, which also extends to the additional nasal cartilages.

Simultaneous recession of the bony and membranous parts of the nasal septum is characterized by flattening of the nasal bones, a defect in the anterior edge of the cartilage of the nasal septum, and indentation of both accessory nasal cartilages, which is manifested by a sharp protrusion of the tip of the nose, which is distressing to the patient.

In addition to cosmetic defects, nose deformities may cause olfactory impairment, difficulty breathing through the nose, nosebleeds, hearing loss, headaches, and increased mental and physical fatigue. Many patients with nose deformities avoid socializing, change jobs, or leave their jobs altogether because of their appearance.

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Treatment of congenital saddle nose depression

When determining the indications for nose correction and choosing its method, it is necessary to consider whether the planned shape of the nose matches the patient's overall appearance. For example, a nose with an absolutely straight bridge and a broken tip looks unattractive, since in this case the face is simplified and loses its individuality; a wide, shortened nose harmonizes with a rounded face; with a sloping forehead and microgenia (retrognathia), even a small nose seems excessively large. A slightly elevated, upturned tip of the nose suits a woman with a Russian face type, and a nose with a slight hump, which gives the face special expressiveness and masculinity, suits a man.

It should also be taken into account that 6-8 months after the operation (during the scarring process) some deformation of the tissues of the tip of the nose will occur and it will drop slightly, therefore in some cases “hypercorrection” is advisable.

It is recommended that nose correction be performed on girls no earlier than 18 years of age, i.e. after the development of the facial part of the skull has finished, and on men - no earlier than 21-23 years of age. At the age of over 40, it is not advisable to perform nose correction, since patients find it difficult to get used to their changed appearance, and sometimes even regret this change.

Treatment of nasal recession is usually carried out mainly by introducing allocartilage, Teflon or silicone. The most ideal material is autocartilage or allocartilage, properly preserved, for example, by lyophilization. When using lyophilized cartilage, complications such as its suppuration after surgery, exposure of the graft or necrosis of the nasal dorsum due to its insufficient preoperative rehydration were very rare.

Plastic masses should be used only in extreme cases, when it is impossible to obtain allocartilage or the patient refuses to "wear cadaveric material". If the surgeon is therefore forced to use plastic, he should opt for silicone rubber (polydimethylsiloxane), the results of which O. D. Nemsalze (1991) spoke very highly of.

Elimination of the defect of the wing of the nose and the adjacent part can be accomplished by means of the stem with its epithelialization using an immersion skin graft according to O. P. Chudakov (1971-1976), which A. I. Pantyukhin et al. (1992) cut out on the frontal or hairy part of the head.

Operation technique (according to G.I. Pakovich)

After anesthetizing the tissues with an anesthetic solution, a "bird" incision is made (according to A.E. Rauer). To prevent the formation of a postoperative retracted scar, the lower edge of the skin in the wound area should be separated by 1-1.5 mm. The skin in the area of the tip and bridge of the nose is separated to a depth of 1.5 cm first with a scalpel, and then with a not particularly sharp narrow raspatory or Cooper scissors. In this case, one should strive to advance in one layer and separate the skin "with a margin": somewhat wider than the implanted cartilage, and with a sufficient amount of subcutaneous fat so that the contours of the cartilage transplant are not visible under the skin later.

In cases where too thin a layer of tissue is separated, the skin over the cartilage will initially be pale and then bluish due to insufficient blood circulation.

The cartilaginous seedling is cut out of the costal cartilage on a wooden sterile board (for support). Considering that the cross-section of the rib has an oval shape, the position of the processed cartilage should be different depending on what shape the insert needs to be made of.

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

If there is no template, the length of the saddle depression is measured before the operation using a sterile stick with a notch on it. This technique eliminates the need for the surgeon to apply a piece of the treated cartilage to the surface of the nose to determine the length and shape of the graft, and reduces the risk of infection.

Having created an insert of the required shape, the gauze swab is removed from the wound and the transplant is inserted into the subcutaneous pocket.

If the depression of the bony part of the nasal septum is not sharp, the periosteum above the nasal bones is cut, peeled away with a raspatory, forming a pocket, and the upper pointed end of the insert is inserted into it, due to which it is well fixed in the wound.

If the saddle-shaped depression of the bony part of the nasal septum is very pronounced, it is impossible to raise the low-stretch periosteum to the required height and place the end of the insert under it. In such cases, its end is placed on top of the periosteum.

When eliminating a depression in the membranous part of the septum, it should be taken into account that the slightest inaccuracy in the fitting of the liner will manifest itself as an unevenness of the nasal bridge immediately after the disappearance of postoperative edema. If the liner is larger than necessary, its upper end is placed on the lower edge of the nasal bones and forms a noticeable protrusion. If the liner is smaller than necessary, the nasal bones rise above it. Therefore, G. I. Pakovich recommends creating a spike and a ledge in the area of the upper end of the transplanted cartilage, due to which a small blind pocket is formed under the anterior edge of the nasal bones. To do this, first, a section of the cartilage of the nasal septum is cut off with a scalpel, the periosteum is cut transversely and peeled off with a raspatory. As a result, the spike of the liner enters under the lower edge of the nasal bones, located on the peeled off periosteum and sometimes reaching the lower edge of the bony part of the nasal septum; The anterior edge of the nasal septum cartilage with the additional nasal cartilages attached to it is placed in the groove of the insert. The lower part of the insert is closely adjacent to the upper edges of the lateral crura of the large cartilages of the wings of the nose, and the lower edge of the nasal bones forms a butt joint with the insert in the form of a lock.

When eliminating the depression of the bony and membranous parts of the nasal septum, it is necessary, firstly, to make a longer and thinner cartilaginous insert, which, unfortunately, is difficult to make notches on, since it can be cut. Therefore, it is better to take such a narrow insert from the central part of a piece of cartilage, equally distant from the perichondrium. As a result, the tension force of individual cartilaginous fibers of the insert will be the same on all sides, and therefore it will not deform after the operation. Secondly, it should be taken into account that with saddle-shaped depressions of the nasal dorsum, congenital underdevelopment of the cartilage of the nasal septum in the anterior-lower part is often observed. Therefore, the insert, placed under the skin of the nasal dorsum with such a deformation, rests only on the nasal bones from below in the form of the cartilage of the nasal septum and falls due to the lack of support. This is facilitated by the pressure of the skin in the area of the membranous part of the nasal septum, 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, breaks the periosteum and noticeably protrudes above the surface of the nasal bridge. Therefore, the lower end of the liner needs to be supported in the form of a rafter from a rectangular piece of cartilage 2.5-3 mm thick, its length should correspond to the height of the missing cartilage of the nasal septum, 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 to the lateral ones. At the end of the rafter facing the anterior nasal spine, a groove is created for resting on the spine (B) 4-5 mm deep. so that it is fixed tightly and does not slip.

At the end of the rafter facing the tip of the nose, a square tenon is created, on the sides of which there are projections (shoulders). According to the size of the cross-section of this tenon, a hole is made at the lower end of the cartilaginous insert, prepared to eliminate the depression of the bridge of the nose. In this way, two cartilaginous inserts are joined.

To determine the height of the rafter and place it in the right place, A. E. Rauer's cut at the tip of the nose is continued down the nasal septum to the lower lip. The skin of the septum is split to the nasal crest, the height of the required rafter is measured (with a steel ruler or a linear instrument) and its modeling is started. Then it is placed between the right and left parts of the split skin of the septum, the stability is checked and connected, as stated above, to the end of the main insert.

If the tenon on the rafter is longer than necessary and protrudes above the surface of the hole in the main insert, its end is cut off to the level of the upper surface of the main insert.

The lower end of the main insert can be shaped to suit the desired shape of the tip of the nose.

If the large cartilages of the alae are developed normally and the tip of the nose has the correct shape (against the background of the recession of the bridge of the nose and in the absence of the membranous part of the nasal septum), the end of the insert can be modeled narrow and placed in the groove between the large cartilages of the alae.

If the tip of the nose is wide and flattened, you can (before inserting the liner) cut off the cartilages of the alae at the transition to the medial crura, and then suture them over the liner. This will raise the tip of the nose and make it rounded.

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

After inserting the cartilaginous insert, pre-treated with a 5% alcohol solution of iodine, sutures are applied along the incision line, both lower nasal passages are tamponed for 1-2 days (to avoid hematoma formation), and a collodion dressing, also suitable for other cosmetic surgeries, is applied to the nose. To make the dressing, square gauze napkins (15x15 cm) are folded in 4-8 layers and carefully smoothed. To ensure that both halves of the dressing are symmetrical in shape, the taken layers of gauze are folded along the midline. From the gauze pieces folded in half, a figure is cut out with scissors, somewhat resembling the profile of a hat. After unfolding the gauze, a butterfly-shaped dressing (B) is obtained, in which two cheek sections, a frontal section, and a section of the tip of the nose are distinguished. The cut layers of gauze are dipped in a glass with collodion and lightly squeezed, then applied to the dry surface of the skin of the nose and cheeks. Use your fingers to shape the bandage into the shape of your nose, reproducing its relief (B). At the same time, squeeze out the blood remaining in the wound, drops of which seep between the stitches.

This dressing hardens in 5-8 minutes, is rigid enough to hold the cartilage transplant in the position specified for it and prevent hematoma formation. In addition, it ensures an aseptic condition of the underlying skin, does not cover the eyes, does not interfere with food intake and facial hygiene.

The collodion dressing is removed 6-10 days after the operation, soaking it in ether or alcohol (whichever is easier for the patient to tolerate). Removing the dressing is made easier by the accumulation of secretions from the sebaceous and sweat glands of the nose and cheeks under it.

Endonasal method of insertion of allochondral liner

The endonasal method of inserting the allochondral liner is more effective than the extranasal method for cosmetic reasons. It is indicated when the nasal dorsum is sunken above the large cartilages of the nasal wings. If the saddle is located lower, it is inappropriate to use the endonasal method of surgery, since it usually results in cicatricial deformation of the nasal wing.

The surgical technique (according to G. I. Pakovich): make a transverse incision (1.5-2 cm long) in the mucous membrane at the border between the aforementioned cartilages; use small curved blunt-ended scissors to peel off the skin above the accessory nasal cartilage, and then in the area of the recession of the bridge of the nose, the tip, and in the area of the wings of the nose. If the area of the separated skin is somewhat longer and wider than the area of the transplant, this will allow it to be installed in the correct position.

In cases where the lower edge of the saddle is located below the mucosal incision, the skin should be peeled off even higher so that the graft can be completely inserted under the skin above the incision. Only after the lower end of the graft has passed the mucosal incision, it is placed in the sunken area with a reverse movement, bypassing the incision.

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 sutured with catgut, the nasal passages are tamponed with gauze strips for 2-3 days. A fixing collodion bandage is applied externally.

When correcting nasal bridge defects with plastic inserts, one should avoid transplanting monolithic explants, as this often leads to stagnation in the skin covering the implant (it becomes bluish, especially when the ambient temperature drops). Sequestration of such inserts is often observed, especially after accidental trauma to the nose.

The data of experimental studies and clinical observations show that the best material for explantation are frame explants made of 0.6-0.8 mm thick Teflon mesh. An external Rauer incision is required when introducing such an explant only when it reaches large sizes; in the case of pronounced curvatures and combined deformations of the nose, external and endonasal (between the alar and triangular cartilage) incisions are made with a sharp eye scalpel.

A lower nasal incision or an internal marginal incision along the ala of the nose is made in cases of depressions of the membranous and bony-membranous parts of the nasal septum, as well as in cases of some deformations of the ala of the nose.

Treatment of congenital deformities and non-unions of the tip of the nose (according to G. I. Pakovich)

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