HANDLING OF THE NASAL DORSUM PUSH DOWN ALVARO CORREA JARAMILLO Medellín, Colombia
I describe my contributions to nasal surgery, making it clear that the original idea of dropping the nasal dorsum keeping intact the outside of the back is not mine, but modifications and standardization of the technique, are based on a personal vision over 3000 surgeries performed with this technique and compared with more than 1000 surgeries realized with the removal of the back technique.
Dorsum resection is difficult because you have to calculate what it is removed and with two different tools: the cartilage with a surgical knife and the bone with chisel or rasp and destroys the roof of the back. When resection is large requires rebuilding the dorsum.
In the push down resection is not the dorsum. It remains intact or with minor modifications and removed in the septum and in the side walls of a small amount of support tissues to produce a decrease in block.
We classify the dorsum into two types: the rectum and having prominence in the union of cartilage with the bone in the dorsum. I call type 1 and type 2
TYPE 1 TYPE 2
For each of these types of different dorsums exists a different size. Generally we classify them into: Small ranging from 0-3 mm and in excess, or 3-6 mm medium, and large over 6mm.
TYPE 1 - Normal & Oversize A B C A- 0-3 mm small B- 3-6 mm medium C- 6 mm or up big
TYPE 2 - Normal, Hump & Oversize A B A normal: only hump B- small: 0-3 mm C- Medium: 3-6 mm D- big: 6 or up mm C D
Remove a lower strip of the septal cartilage and make an osteotomy in the perpendicular lamina of the ethmoid and join with resection of basal strip. Paramedian osteotomies are made, and oblique and lateral also.
Paramedian osteotomy reaches at the intercantal level and continue with oblique, to avoid thickening of the bones at this level, and joining with the lateral osteotomy, leaving the dorsum free.
septum 3 0 4 1 5 2 6 3 7 4 8 5 9 6 10 7 Lateral wall
In the previous slide has explained as the gap between what is removed in the septum, (the loss of support at the level of the nasal spine) and lateral wall resection. Remember that is not necessary to keep out the strip of the bone, only make a simple double osteotomy. But the separation of the osteotomy should be 4mm less than the center resection. In this way we prevent the head of the inferior turbinate to stop the descent of the pyramid.
In the descent of the dorsum you must take care that this falls more into the nasal spine and the level of osteotomy side pyriform aperture descends less than 4mm in nasal spine. As seen in the figure, the head of the inferior turbinate can stop the decline of the side wall, so it is necessary to double lateral osteotomy when exceeding 4mm wide resection of the nasal spine.
Literally we have a unique piece, a new anatomical unit composed septum (bonecartilaginous), upper lateral cartilages and bones attached to soft tissue side. In case you have separated lateral septum cartilage to the septum, you only have to join them to repair the anatomical unit.
The amount to be removed to the author is not artistic mathematics. Based on anthropometric work septum height in personnel and aesthetically well-considered normal. The rule is 18mm height in men. and 17mm for women. We consider maximum 1mm or 2mm in averages and 3mm margin but never in excess.
The measure you leave
Here the advantage is obvious compared to resection of the dorsum, and not based on experiences of appreciation that take a long time to learn and carry right - mistake. With the push down technique, just enough to take well the measure that we leave and we do not care what we remove. Anything contrary happens with resection of the dorsum, take care only what removes and has no control over leaving.
The basic technique described here is only one type of back when we just rasp dorsum type 2 prominence in rhynion and in some cases we have to use scalpel to remove a small amount of cartilage, not being separated from the septum, but if it should occur for any reason simply is reconstructed by joining the elements.
Some authors describe very well the technique of push down for type 2, and do not describe the technique for type 1. In my practice, I found relapses between 10% and 20%, which to be corrected. I had to rasp subsequently proceed. With the vision of turning dorsum type 2 in type 1 the problem disappeared. Today I only recommend the technique for type 1 and in case dorsum type 2 changes at type 1.
For some authors, the push down is dividing into two fragments the septum. The former is mainly cartilaginous and osseous component for more later. Some have added a small step that is supported at the end opposite the nasal spine.
In a number of cases like this, I got good results, but do not allow variables to be sure of the result. So I recommend turning the dorsum type 2 and type 1 in the technique of push to do down always this way.
The method of calculating the dorsum resection comparing the difference between the real and the ideal; real size photos. In my observations is not accurate and leads to errors, today only recommend, take the measure of what we will leave 18 mm to 17 mm for men and women.
This method is mathematics not artistic or Heuristic and assumes that define the height of the dorsum and finally then working the tip.
RASP HUMP IN TYPE II PERFORME ACCESS TO THE SEPTUM TAKE THE MEASURES AND REMOVE THE STRIP PARAMEDIAN, OBLICUE, VERTICAL AND LATERAL OSTEOTOMY MAKE THE SYSTEM STABLE
TIPS IN PUSH DOWN Suitable approaches open or closed Convert the dorsum type 2 in type 1 with rasp remember that removes more cartilage and bone that this can be higher in 1 mm to solve this must be cut cartilage, 1 mm. Remove the strip in septum and leaving between dorsum and nasal spine 18 mm for men and 17 for women.
TIPS EN PUSH DOWN If for some reason voluntary or accidental septum separates the lateral cartilage, these must unite again and do not affect the result. The double osteotomy is mandatory in cases where more than 3 mm exceed a resection basal strip nasal spine to prevent the inferior turbinate head stop the descent of the sidewall.
TIPS IN PUSH DOWN The osteotomies should be effectively pursued should verify all and especially the perpendicular plate of the ethmoid and lateral, should not be broken green wood. The cause for the decline of not having to do with some incomplete osteotomies, a side wall hits the head of the inferior turbinate or through support to the vomer, post nasal spine, the lower point of contact unic should be the nasal spine Stabilize the system.
The mobility of the unit back and septum created must be total, it must have adhesions as this causes undescended. Stabilize the system in the nasal spine is basic, must unite the periostium above and in front of the nasal spine.
If expanders placed grafts or separate lateral septum cartilage, reconstruction should be done on the dorsum before the osteotomy perpendicular to the lamina of the ethmoid.
SUMMARY
SOME RESULTS
Push Down is not a popular technique. Push Down has few teachers. Push Down needs especial knowledge. The skill to make Push Down is the same as in twisted nose.
Resection of the dorsum has good results in small noses. Resection in the dorsum needs reconstruction in medium and big noses. If you make funcional and aesthetic surgery, Push Down is the best choice.
Natural and good results. No damage to the valve. The contraction of the skin in the rhinion is less. It is a mathematical surgery. Helps you save time.
Add rotation to the tip. Avoid repair dorsum more times. It is possible with another surgery like expreader graf, dorsum reconstruction, functional surgery, in all conditions. First indication is in big noses.
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