肋软骨跨穹窿盖板移植物联合鼻前庭V-Y推进皮瓣矫正鼻翼缘退缩畸形

Extended trans-dome onlay graft combining nasal vestibule V-Y advancement flap for correction of alar retraction

目的探讨应用肋软骨跨穹窿盖板移植物联合鼻前庭V-Y推进皮瓣矫正鼻翼缘退缩畸形的临床效果。方法回顾性分析2019年7月至2020年10月于重庆华美整形外科医院收治的鼻翼缘退缩患者的临床资料。取患者右侧第6或第7肋软骨制作鼻整形所需的移植物(其中包括应用肋软骨皮质部分制作的薄片状盖板移植物);切开鼻前庭时设计V形皮瓣, 在施行肋软骨鼻综合整形手术处理鼻部其他美学亚单位后, 于鼻翼皮肤及鼻前庭皮肤间沿皮下充分分离至鼻翼缘并形成囊袋样腔隙, 将盖板移植物固定于鼻尖, 两侧软骨片分别插入囊袋内, 使其为鼻翼缘下移提供支撑力, 通过V-Y推进缝合鼻前庭皮瓣为鼻翼缘下移提供软组织, 并在鼻翼内外两侧用夹板固定。术后从以下3个方面对手术效果进行评估:(1)鼻翼缘退缩改善满意度。术后由患者本人及2位未参与手术的鼻整形医生分别通过视觉模拟评分法(VAS)对鼻翼缘退缩改善程度进行评分(总分为0~10分, 9、10分为满意, 7、8分为基本满意, 0~6分为不满意), 统计术后满意例数占总例数的百分比。(2)鼻翼对称度, 即鼻翼对称例数占总例数的百分比。(3)正位标准照a/b值(a为两侧鼻翼缘退缩最高点连线-鼻尖表现点水平线间距, b为两侧鼻翼缘退缩最高点连线与鼻小柱-小叶转折点水平线间距)。采用Image J软件测量并计算正位标准照中的a/b值, a/b=1或a/b稍>1表示鼻翼缘位置正常, a/b<1为鼻翼缘退缩。应用SPSS 20.0软件进行统计分析, 鼻翼对称度术前和术后比较采用卡方检验, 正位标准照a/b值以±s表示, 术前和术后比较采用配对t检验, 不同分型组间两两比较采用SNK法, P<0.05为差异有统计学意义。结果共纳入43例鼻翼缘退缩患者, 男5例, 女38例, 年龄18~45岁, 平均27.3岁, 其中内侧型17例、中央型22例、外侧型4例。术后随访时间为1~24个月, 中位数为4个月, 随访过程中无鼻翼皮肤缺血坏死、台阶样改变、鼻翼缘挛缩变形等并发症发生, 鼻翼缘未发生再次退缩的情况。其中4例鼻前庭切口处出现不同程度的增生性瘢痕, 经曲安奈德注射后改善;1例术后鼻翼缘仍不对称, 经手术调整后改善。患者术后VAS评分为(8.93±1.12)分, 满意度为81.4%(35/43);2位医生VAS平均评分为(8.93±1.04)分, 满意度平均为81.4%(70/86)。术后鼻翼对称度为93.0%(40/43), 较术前的58.1%(25/43)有明显改善(P<0.01)。正位标准照a/b值从术前的0.79±0.06改善为术后的1.00±0.04(P<0.01), 不同分型组间两两比较, 差异均无统计学意义(P均>0.05)。结论肋软骨跨穹窿盖板移植物联合鼻前庭V-Y推进皮瓣可有效矫正多种类型鼻翼缘退缩畸形, 提高双侧鼻翼对称性, 医患双方满意度高。

Objective To investigate the effect of using extended trans-dome onlay graft(eTDOG)made of costal cartilage combined with nasal vestibule V-Y advancement flap for correction of alar retraction.Methods Clinical data of patients diagnosed with alar retraction at Chongqing Huamei Plastic Surgery Hospital between July 2019 and October 2020 were retrospectively analyzed.The 6th or 7th right costal cartilage was harvested,cut into pieces for grafts,including a laminar trans-dome onlay graft,made from cortex part of the rib.Then a V-shaped flap was designed on the vestibular skin.At the end of the rhinoplasty,a pocket was created along the alar rim,and the eTDOG was inserted into the pocket to push down the alar rim.Nasal vestibule V-Y advancement flap provides extra soft tissue for alar retraction correction.Splints were applied to hold the eTDOG and flap in place.Assessment of therapeutic effect was made from three aspects.First of all,therapeutic satisfaction assessment,which was made based on the visual analogue scale(VAS).VAS scoring was conducted by patients and two surgeons who were not involved in surgery.Results were divided into three categories,total satisfaction with scoring 9 or 10,partly satisfaction with scoring 7 or 8,and dissatisfaction with scoring 0-6.Subsequently,the percentage of satisfaction indeed in the total number of cases was counted.Alar symmetry assessment was also included.The percentage of cases with alar symmetry in the total number of cases.Third,the ratio(a/b)of the distance between the line defined by bilateral highest points of alar retraction and the line determined by tip-defining points(a)to that between the line determined by bilateral highest points of alar retraction and the horizontal line defined by the turning point of columella lobule(b)was calculated on frontal view.The value of a and b was measured using Image J,and a/b<1 represented absence of alar retraction.The statistical analysis was performed using SPSS version 20.0.Chi-square test was used to compare the symmetry of alae pre-and post-operation.Values of a/b were expressed as Mean±SD,and was compared using t-test.SNK were used for comparison among and between groups of different types,respectively.P-value less than 0.05 considered to be statistically significant.Results Forty-three cases were included in this study,including 5 men and 38 women,with mean age of 27.3 years(18-45 yars).Among them,medial,central and lateral type of alar retraction was comprised of 17,22 and 4 cases,respectively.The median follow-up time was 4 months(range,1-24 months).During the follow-up,no complications like avascular necrosis of ala,step like deformity or alar contracture were observed,so was the recurrence of alar retraction.A total of 5 complications were observed,including 4 cases of hypertrophic scar at the incision which were improved after injection of Triamcinolone and 1 case of remaining alar asymmetry which was corrected by reoperation.The VAS score of patient was 8.93±1.12,and patients with satisfaction indeed accounted for 81.4%(35/43).The mean VAS score of the two operation-non-participated surgeons was 8.93±1.04;and cases assessed to be satisfaction indeed accounted for 81.4%(70/86).The proportion of symmetric alae significantly improved from 58.1%(25/43)to 93.0%(40/43)(P<0.01).The ratio of a/b decreased from 0.79±0.06 pre-operation to 1.00±0.04 post-operation(P<0.01).While no significance was found among groups neither pre-nor post-operation(P>0.05).Conclusions eTDOG made of costal cartilage combining nasal vestibule V-Y advancement flap is an effective method for correction of all types of alar retraction and improvement of alar symmetry,with high satisfaction of patients and surgeons.