Osteotomy_현우_발표[1].pptx
description
Transcript of Osteotomy_현우_발표[1].pptx
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Osteotomy & hump reduction
GNUH ENT R4 Park Hyun-woo
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Osteotomy
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Osteotomy
• Types - Medial - Intermediate - lateral
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목적• Bony pyramid 폭의 감소• Hump resection 후 발생하는 open roof
deformity 의 교정• deviated nose 의 교정 – controlled
fracture
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분류• Endonasal / percutaneous osteotomy
• Complete osteotomy - percutaneous• Incomplete osteotomy – endonasal
• Medial / lateral / transverse os-teotomy
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효과• Bony pyramid 가 좁아진다• Bony pyramid 가 높아진다• Bony pyramid 방향이 교정
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그림 1
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그림 2
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그림 3
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그림 4
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osteotome 의 선택• 작은 osteotome : less bleeding, but
weak• 큰 osteotome : easy complete os-
teotomy but more bleeding• Guarded osteotome : 걸기 편하고
미끄러짐이적고 촉지하면서 osteotomy 가능
• Curved : lateral osteotomy• Straight : lateral/medial osteotomy
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medial osteotomy
• Nasal bone 으로부터 septum 을 분리• Lateral osteotomy 작용을 도움• 3-4mm 폭의 straight guarded osteotome 을 이용• 15 번 수술칼이나 D-Knife - ULC 와 비중격 사이에 절개• NB 의 하단부 (Open roof 의 상단부 ) ~ nasion 까지 • 단일로는 효과 없음• 의의 : Bony septum 을 보존하면서 lateral os-
teotomy 후 만들어지는 뼈조각이 원하는 모양으로 꺾일수 있도록 함 .
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그림 6
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• 반드시 lateral osteotomy 시행 전에 함 .
• Open approach– ULC 에서 septum 을 분리한 후 그 면에서
nasal bone 에 osteotome 을 걸고 inner canthus 를 향해서 진행 (15~25o) 하거나 paramedian 으로 평행하게 진행
– 지나친 paramedian – rocker-bottom de-formity
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그림 7
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그림 8
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• ULC 와 septum 을 분리 하지 않았을때
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그림 11 - 주의사항
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Lateral osteotomy
• Internal continuous lateral osteotomy– Local injection– IT 기시부위의 pyriform apperture 에서 periosteum 까지
이르는 절개– Osteotomy 를 하려는 가상선을 따라 진행– nasomaxillary groove 로 올라가다가 안와하연에서 내측으로
연장 , 내측절골선과 연결– 터널은 내측절골술이나 hump 의 제거로 생긴 터널과 연결되지
않도록– osteotome 을 오른손으로 연필잡듯이 잡고 외측상방 ,
내측상방으로 방향전환– 손가락으로 절골도의 끝을 더듬어 끝이 상악골전두돌기의 기저부에
있음을 확인
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그림 13
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그림 14
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• High osteotomy 시 발생하는 stair step deformity
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• Percutaneous lateral osteotomy– Nasofacial groove 의 약간 medial 에서 절개– Angular artery 보호– Osteotome insertion 후 아래로약간 당기면서
osteotomy 시행
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그림 17
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– 연속적인 절개선이 아니라 연속적인 작은 구멍을 만들어 시행
– 2mm osteotome– Caudal (thin) cephalo-medial (thick)
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그림 18
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– 장점 : 수술중 시야확보가 용이 , 점막 손상 적음 , 출혈 적음 , 술후 부종 경감
– 단점 : 뼈가 두꺼운 사람은 어려움 , osteotomy line 의 정확한조절이 어려움
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Transverse osteotomy
• Paramedial 에 가까운 medial os-teotomy 와 low to low lateral os-teotomy 를 연결하기위해 시행
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• 양 미간정도 level 에서 2mm osteotome• Cartilage septum 의 dorsal part 가
ULC 와 분리 되어 있어야 한다 .
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고려사항 & 금기사항• 뼈의 두께– Thick : lacrimal crest 근처 , 반대측 nasal
bone 과의 junction– Thin : lateral osteotomy 시작 부위– Nasal bone 이 작고 두꺼운 경우 또는 os-
teotomy Hx. 가있는 재수술일 경우 조각조각 골절이 발생 할수 있으므로 onlay graft 가 더 좋음 .
– Comminuted fracture dorsum augmen-tation
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합병증• 출혈 – compression, packing, splint– Cauterizatioin 금기– 예방 : 수술전 국소 점막 수축제 , 작은 osteotome,
periosteum 부착 유지• 부종• 모양 변형 – incomplete osteotomy• Callus 형성• Inverted V deformity – nasal bone 과 ULC
junction 함몰 • Bony dorsum irregularity• 후각장애 , 코막힘 , lacrimal apparatus 손상
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Lateral (low osteotomy)-> Nasolacrimal duct injury
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Low start or vertical -> Nasal obstruction
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Dorsal hump reduction
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그림 1
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미용적 고려사항• Dorsal aesthetic line- 적절히 보존• Supraorbital ridge – corrugator –medial canthal ligament – keystone area – tip defining point
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그림 2
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그림 3
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Dorsal hump 의 분류• Isolated hump• Generalized hump• Deviated nose 와 동반된 hump • pseudohump
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Isolated hump
• Dorsal line 에서 작은 hump 가 삼각형의 형태로 갑작스럽게 돌출되어 있는 경우
• 외상 병력이 많다 .• 주로 bony vault, rhinion
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Generalized hump
• Bony vault 로부터 시작하여 cartilage dorsum 까지 완만
• 외상병력이 없는경우가 많다 .• 주로 발달상의 문제• 주로 cartilaginous portion 부분에서
절제해야함 .
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Deviated nose 와 동반된 hump
• 많이 동반• Dorsal hump reduction 과 함께 devi-
ated nose 에 대한 교정도 동시에 함 .
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Pseudohump
• Dorsal hump 가 있으면서 cartialginous dorsum 의 높이가 낮아져 있는경우
• 교정 : dorsal hump reduction 뿐만 아니라 cartilaginous dorsum 에 대한 augmentation, caudal septum 의 support 를 강화
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수술방법
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Endonasal approach
• Anterior septal angle 에서 시행한 In-tercartilaginous incision 사용
• 연골과 연부조직의 분리• Nasal bone 의 subperiosteal dissec-
tion• Cartilaginous vault 절제 – No 15• Osseocartilaginous hump resection• Rasping• Open roof deformity osteotomy
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그림 8
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Open approach
• Marginal incision & transcolumellar incision
• Bony vault – subperiosteal plane
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그림 10
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그림 11, 12
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• ULC reduction – internal nasal valve 폐쇄 주의
• Spreader graft c septal cartilage– Dorsal nasal roof 의 유지와 재건– Internal nasal valve 의 복구와 유지– Dorsal aesthetic line 의 재건– 5-PDS – horizontal mattress suture - sep-
tum– 4-PDS – ULC, spreader graft, septum
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Osteotomy
• Open roof deformity 의 교정
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dorsal hump reduction 에서 dorsal augmentation 과 tip surgery
• Hump 환자들에서 많은 예에서 underpro-jected tip 이 동반
• tip projection & support 를 개선 시키는 술식이 추가
• 적당한 dorsal augmentation
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그림 16
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합병증 및 주의 사항• Rasping 후 dorsum irregularity ir-
rigation or graft material• hump 의 과한 절제 – hump 를 다듬어서
다시 삽입 (Skoog’s method), septal cartilage graft
• Inverted V deformity – nasal bone & ULC
• Polly beak deformity
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• Polly beak deformity– Soft tissue polly beak – soft tissue scar– Cartilaginous polly beak – 연골부의 소극적
절제 또는 골부의 과도한 절제– Relative polly beak – 술후 경과에서
발생하는 tip drooping
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