Dr Rahul Tiwari OMFS SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh. MANAGEMENT OF SADDLE NOSE DEFORMITY USING DERMAL FAT AND COSTAL CARTILAGE “SANDWICH” GRAFT - A

05/02/2023 12:14:07 AMRT/JC/07/SANDWICH TECHNIQUE FOR SADDLE NOSE DEFORMITY/30. 1

GOOD AFTERNOON

JOURNAL CLUB – 07.

Presented byDr. Rahul Tiwari

Final Yr. PGOMFS - SIDS


TITLE & AUTHOR

• MANAGEMENT OF SADDLE NOSE DEFORMITY USING DERMAL FAT AND COSTAL CARTILAGE “SANDWICH” GRAFT - A Problem-Oriented Approach and Anthropometrical Evaluation.

• Onder TAN, Professor, MD, Said ALGAN, Assistant Professor, MD, Hakan CINAL, Specialist, MD, Ensar Zafer BARIN, Specialist, MD, Murat KARA, Resident, MD, Akin INALOZ, Resident, MD

• Ataturk University, Faculty of Medicine, Department of Plastic Reconstructive and Aesthetic Surgery, Erzurum / Turkey


CORRESPONDING AUTHOR

• PROF. DR. ONDER TAN• ATATURK UNIVERSITESI TIP FAKULTESI• YAKUTIYE ARASTIRMA HASTANESI• PLASTIK REKONSTRUKTIF VE ESTETĐK CERRAHI A.D.• 25240 – ERZURUM / TURKEY• Tel : 00. 90. 442. 3447020• Fax: 00. 90. 442. 2361301• E-Mail : [email protected]; [email protected]


JOURNAL & ARTICLE

• PII: S0278-2391(16)30154-9• DOI: 10.1016/j.joms.2016.05.007• Reference: YJOMS 57265• To appear in: Journal of Oral and Maxillofacial Surgery• Received Date: 31 March 2016• Revised Date: 28 April 2016• Accepted Date: 9 May 2016


INTRODUCTION

• SND (SADDLE NOSE DEFORMITY)

• LOSS OF HEIGHT & CONTOUR OF NASAL DORSUM

• RESULTS FROM TRAUMA OR PREVIOUS SEPTORHINOPLASTY OPERATIONS

• IT IS A SERIOUS ISSUE OF AESTHETICS COMPROMISE

• CORRECTION IS QUITE HARD

• THERE IS NO GOLD STANDARD MATERIAL & TECHNIQUE AVAILABLE SO FAR


MATERIALS USED

• ALLOPLASTIC IMPLANTS, CADAVERIC TISSUES SUCH AS CARTILAGE, FASCIA LATA

(TUTOPLASTTM) AND ACELLULAR DERMIS (ALLODERMTM), AND VARIOUS

AUTOLOGOUS TISSUES SUCH AS BONE, CARTILAGE AND FASCIA.


REVIEW OF LITERATURE• VARIOUS IMPLANTS SUCH AS SILICONE, PROTOPLAST, POROUS POLYETHYLENE

(MEDPORETM), POLYTETRAFLUOROETHYLENE (GORE-TEXTM) UTILIZED TO ENSURE NASAL HEIGHT HAVE QUITE HIGH COMPLICATION RATES MAINLY INCLUDING INFECTION, EXTRUSION AND DISPLACEMENT.


REVIEW OF LITERATURE

IF OVER-RESECTION IS PERFORMED OR THE VITAL SUPPORT POINTS ARE NOT ADEQUATELY

PRESERVED IN SUPPLEMENTAL SURGICAL INTERVENTIONS TO THE SEPTUM, MUCH MORE

SERIOUS SNDS MAY APPEAR.

THE IMPORTANCE OF THE PROTECTION OF NASAL TIP AND DORSUM SUPPORT FOR A

SUCCESSFUL RHINOPLASTY IS VERY IMPORTANT CRITERIA.









•

430 CASES – 674 GRAFTS – 96% SUCCESS

USE OF SURGICEL WRAPPED DICED CARTILAGE ON 2365 CASES WITH 1 YEARS FOLLOW UP & TOTAL 10 YEARS STUDY



•

90 CAESES – 80% SUCCESS

21 SUBJECTS - COMPLETE SUCCESS



SEPTAL CARTILAGE OR ETHMOID BONES WITH ALLOGENOUS FASCIA LATA (TUTOPLASTTM),

18 CASES – 2008 TO 2011 – 15 MONTHS – NO RESORPTION

8 CASES – 2 YEARS – EXCELLENT RESULTS


PURPOUSE

• PREPARED A COMPOSITE “SANDWICH” GRAFT BY CAMOUFLAGING THE

COSTAL CARTILAGE UNDERNEATH THE DERMAL-FAT GRAFT AS A NOVEL

METHOD AND APPLIED IT ON DIFFERENT SNDS IN SEVERITY WITH THE

CLOSED RHINOPLASTY TECHNIQUE TO PREVENT OR MINIMIZE THESE RISKS.


PATIENTS & METHODS

• 21 PATIENTS (12 M & 9 F) – 2010 TO 2014.

• 18 TO 53 YRS WITH MEAN OF 29.14 YEARS.

• ETIOLOGIES:

• PREVIOUS SEPTO AND/OR RHINOPLASTY OPERAIONS – 14.

• TRAUMA – 4

• CONSTITUTIONAL DEFORMITY – 3.


ANATOMY

•


SND CLASSIFICATION• TYPE 1: DEFORMITY, WHICH HAD A SERIOUS HEIGHT LOSS AND WAS LIMITED ONLY ON THE

NASAL DORSUM. NASAL TIP AND SEPTUM SUPPORTS WERE PRESERVED.

• TYPE 2: DEFORMITY, IN WHICH LOSS OF NASAL TIP SUPPORT ACCOMPANIED THE DORSAL

HEIGHT LOSS. (15 SUBJECTS)

• TYPE 3: DEFORMITY, IN WHICH LACK OF MIDDLE AND/OR POSTERIOR SEPTAL SEGMENT

ACCOMPANIED THE LOSSES OF DORSAL HEIGHT AND NASAL TIP SUPPORT. (6 SUBJECTS)


DEMOGRAPHIC DATA OF THE PATIENTS AND CARTILAGE GRAFTS USED ACCORDING TO THE TYPE OF SND• SEPTAL STRUT GRAFT AS L- STRUT.• ADDITIONAL SEPTAL BLOCK GRAFTS.

• SEPTAL SPLINTS – 15 SUBJECTS• SEPTAL BLOCK GRAFT – 6 SUBJECTS• SPREADER GRAFT – 10 SUBJECTS• COLLUMELLAR STRUT GRAFT – 3 SUB.• MEDIAN & LATERAL OSTEOTOMIES

PERFORMED IN 19 SUBJECTS


SURGICAL TECHNIQUE

• INTRACARTILAGENEOUS & TRANSFIXATION INCISION BY USING CLOSED RHINOPLASTY TECHNIQUE UNGER GA.

• 6TH 7TH or 8TH COSTAL CARTILAGE WITH DERMIS & FAT TISSUE (COMPOSITE GRAFT)

• THE GRAFT & DERMIS SUTURED WITH 4 -0 POLYDIAXONE & THEN PLACED AT THE DONOR SITE.

• FIXATION SUTURES ON GLABELLA & NASAL TIP. REMOVED AFTER A WEEK.

• POST OPERATIVE NASAL PACKS & ANTIBIOTICS OINTMENTS PLACED IN NASAL PASSAGES.


COSTAL CARTILAGE GRAFTS WITH DERMIS & FAT


RECIEPIENT SITE


EVALUATION

• CLINICAL AND PHOTOGRAPHIC EXAMINATION.

• FRONT, SEMI BASAL, BASAL, LEFT AND RIGHT OBLIQUE & SIDE VIEWS.

• IMAGE J TM PROGRAM ON PRE & POST OPERATIVE LATERAL CEPHALOGRAPS


LINEAR MEASUREMENTS

NASAL DORSUM PROJECTION NASAL SUPRA TIP PROJECTION NASAL TIP PROJECTION NASAL LENGTH


ANGULAR MEASUREMENTS

LABIO-COLUMELLAR ANGLE

NASO-FRONTAL ANGLE


STATISTICAL ANALYSIS

• SPSS VER 18

• MEAN, STANDARD DEVIATION, MINIMUM & MAXIMUM VALUES CALCULATED IN

PRE & POST OPERATIVE GROUPS.

• PAIRED SAMPLE T TEST

• P VALUE < 0.05 (STATISTICALLY SIGNIFICANT).


PRE & POST OPERATIVE PICS


RESULTS - ANTHROPOMETRICAL MEASUREMENT


CONCLUSION

• SEVERITY OF THE DEFORMITY SHOULD BE EXACTLY DETERMINED PRIOR TO

OPERATION.

• MOST IDEAL GRAFT IS STILL COSTAL CARTILAGE

• SANDWICH TECHNIQUE MINIMIZE POTENTIAL COMPLICATIONS AND REVISION RISKS.

• IT IS PRACTICAL, EFFECTIVE & LONG LASTING TREATEMENT METHOD.


LIMITATIONS

• FURTHER SERIES BASED ON LARGER SERIES AND HISTOPATHOLOGICAL

EVALUATION OF THE BIOPSIES TAKEN FROM RE OPERATED PATIENTS MAY REVEAL

THE LATEST RESULT OF COMPOSITE GRAFT.

• NO OBJECTIVE METHOD IS AVAILABLE FOR THE EVALUATION OF THE OUTCOMES

OF AESTHETICS AND RECONSTRUCTIVE INTERVENTIONS OF ALL FACIAL AREAS,

MAINLY THE NOSE, YET.


THANK YOU

Health & Medicine

Dr Rahul Tiwari OMFS SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh. MANAGEMENT OF SADDLE NOSE DEFORMITY USING DERMAL FAT AND COSTAL CARTILAGE “SANDWICH” GRAFT - A