Риносептопластика

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MUHMO MenHUMapoe

Muhho Me/iHi/iHapoB
PI/IHOCEnTOn/lACTMKA
AeaHrapfl flpuMa
Co4)Ufl, 2008

Ha Huna u Kpucu!
Pl/1H0CEnT0n/lACTMKA
© MMHHO MenHunapoB, aeiop, 2008
ISBN 978-954-323-467-7
l/lBflaiencTBO „AeaHrapfl flpuMa"
CO4)MA, 2008
CHMMKM M RPA4)MKH - L/LHTEPHEI
Fpac^nKn no fleo MeTqeHÖayM

nPEAFOBOP
„Po6"bT ce CTpeMU K"bM CBOÖOfla,
a CBOÖOflHMflT - KTdM CbBtpiiieHCTBO"
CaHflancKn
CTpeMe>K"bT KbM CbBtpiiieHCTBO Kapa CbBpeMeHHMa HO-
bck Bee noBene
fla nome^Kfla k^m nnaciMMHara xMpyprna.
HaiMCKtT sa nofl^araHe Ha nnacinHHi/i onepaMMH b ctspe-
MeHHoro MH(J)0pMai4M0HH0 oömecTßo ce 3acMnBa n or nflea-
nusupaHMie o6pa3M na nyöni/iHHM ^mhhoctm, cnopiHM u
MOflHM MflO/IM, apTMCTM, fieBMH l/l My3MKaHTM.
MacoBoro HaBnM3aHe na Mo^epnH rexHO/iorm/i b MeflM-
LiMHaia, flOBe^e flo cbLuecTBeno yflb^>KaBaHe na aKTMBHaia
nacT OT >KMBOTa hm. HeMnnyeMO öoraTMTe n ycne^HTe MCKaT
fla M3rne>KflaT n0-fl06pe-aK0 Mo>Ke nep({)eKTH0-HG3aBi/icnM0
OT reneTUHNM, pacoBM \A nHflMBUflya^HM 0C06eH0CTn. M TyK
ce HaiviecBa nnacTMHHaTa xMpyprna. CHUTaHui flocKopo 3a M3-
nmuHi/i, flopn BpeflHM, njiacTi/iHHi/iTe onepaqnM 3aexa Bofleu^o
m^cto npeflMMHO b KOMepcua/ieH nnaH. Te flaBaT HeBepo^T-
Hi/m niaHC fla flOBtpiuuM fle^OTO Ha C"b3flaTe^a b nocoKa, ko-
hto Hue >Ke/iaeM.
OnepaMMMTe b oö/iacrra na nocnaTa nupaiviMfla npec-
neflBaT flBe BsamviHO CBbp3aHi/i Me/in- ecTeTMKa M (j)yHKi4Ma.
Te3M
flBe qenn ne MoraT fla ö-bflaT npec/ieflBani/i pa3lqeTieHn
eflHa OT flpyra. >Ke/iaHi/mTa m HaMepenn^Ta Ha nauneHTHTe
ne MoraT .qa ötflaT onpaBflanne na KOivmpoMncnTe c (j)yHK-
qi/i^Ta na noca, Tana necTO npefl^araHM OT ecTeTi/iHHi/iTe xu-
pyp3M.
HaMepenuaTa HM npn nanncBaneTO na T03M Tpyfl ca fla
ce CMCTeMaTM3npaT 3HaHi/mTa m onMTa, npuflOÖMTM npe3 ro-
flMHMTe b oönacTTa na pnHonnacTHKaTa, KaKTO m fla ce npeflc-
TaBi/i eflHO ptKOBOflCTBO step by step npn oöyMeHHeTO Ha
3

jieKapn, cneMi/ia/ii/isupau^i/i B oönacTia na puHonoruHra
ripeflCTaB^Me ocHOBHme onepaiHBHH T6XHMKH npn
onepaMMM Ha HOCHaia nperpafla M HOCHaxa nMpaMMfla. CMC-
TeMaTM3MpaHeTO MM 6M cnoiviorHa/io M npM CBSFLABAINE HA Ta-
Ka >KENAHMTE CTanflapiM B OPJl. flocoHeHM ca M KPMTMHHMTG
TOHKM NPM M3N-bfiHeHMe na onepaiMBHMie TGXHMKM.
BceKM, HaB/iRstfi B noneio na nnaciMMHaxa xMpyprM^,
rp^ÖBa fla 6-bfle na^cno, ne pesymaiMTe He MflBai Beflnara, M
KpMTMHHOCTra npM OMeHKaia MM e ABOMHO no BMcoKa,
4

PEUEHSM^
OT AOL;.
fl-p MsaH Ha/rbKOB, A.M.
Hana^HMK I VHr OTfle/iehme Ha VHr HjinnnKa
npn VMBATI „Uapmia MoaHHa-MCy/1" EOOfl
npeflciaBeHMflT MM sa peMenBu« ipyfl B pasMep na 105
MamMHonucHM cipannqn pasme^fla cucreMHO npoöneMa
npn onepaqMUTe na Hoca no noBOfl sarpy^HeHO HOCHO flu-
iiiaHe. AKqeHTtT Ha M0H0rpa(t)i/mTa e nociaBeH Btpxy M3pa-
öoTBane na ptKOBOflciBO „ci-bnKa no crbnKa", 3a MSBbpiiiBa-
ne Ha onepaquMie na noca n HOCHaia nperpafla, Koeio ro
npaBM OGOÖeHO qeHHO npM oGyneHneTO na HaHeBaLume XM-
pypsn.
MoHorpa^M^ia BanoHBa c floöpe noflHeceHa aHaioMMR,
4)M3M0/i0rM« i/i eMÖpi/ionorna na noca. CneMManHO M^CTO e
OTfle/ieHO 3a HeoöxoflUMme npeflBapmejiHM i/i3c;ieflBaHi/m
na naqneHTMie. 14e4)a^OMeTpMHHM«T M (^OTOMerpHHHu^T
aHaiiM3M noMarai 3a npeflBapmeinHOTO nnaHnpane na one-
paqnnTe B oönacrra Ha noca.
CneMMa/iHaia naci 3anoHBa c
fleiaM/iHOTO pa3me>KflaHe
na cenTon/iacTi/iKaia - 6a30Ba onepaqua npM 3aTpyflHeHOTO
HOCHO fluiuaHe. flpocnefl^BaT ce OTfle/IHI/iie eianM, Karo ce
aKqeHTupa Btpxy B'b3MO>KHi/iTe rpeiuKM, KaKio M rexHure
nocneflMLju. OnepaiHBHaia rexHMKa e M/iiocTpi/ipaHa c floöpe
noflöpanM cxeMM, noKa3Bami/i OTfle^nme eiann. npeflcraBe-
HM ca M onepaqnn na Hocnaia nupaMMfla, Kaio ca flucKyiM-
pann npeflMMCTBaia m HeflOCTaT-bquie na pa3/iMMHMTe nofl-
xoflu npn pnHOcenion^acTHKa.
HaKpaa aBTopbi npeflcraBfl m TMnnMnme yc/io>KHeHM«
npn XMpyprua na noca, KaKio I/I Ham/IHI/ire 3a npeoflO^HBane-
TO UM.
Ha^nqe e M öoraia 6i/i6/iMorpa4)CKa cnpaBKa OT ÖT^rapc-
5

KM M Hy^KflM aBTOpM.
npeflCTaBeHaia M0H0rpact)Ma L^e ötfle Menno noMarano
npM oöyHeHMeio Ha cneMManMCTMie 0T0pMH0fiapMHr0/i03M,
KaKio M na xMpyp3M, nocBeTM/IM ce na ecTeTMHecKaTa M (|)yH-
KLiMona/ina XMpyprM^ na noca.
floq. Ha/rbKOB
6

C"bA"bP>KAHME
1.1. EMÖpMOHanHO paaenTne Ha noca n OKO^OHOCHnie
KyXMHM 9
1.2. K^MHMHHa anaTOMMfl na Hoca 12
1.2.1. CemyM 12
1.2.2. BbHLUHn CTenn Ha noca 1 7
1.2.3. Hocna nupaMMfla 20
1.3. K/iMHMMHa aHaiOMUfl Ha cnnycMTe 23
1.3.1. MaKCi/maia e Hai/i-ro/iflMaia nnqeea KOCT cnefl
MaHflnöynaTa 23
1.3.2. ETMOHflanen /ia6npnHT 25
1.3.3. C^eHOMflanen cunyc 27
1.3.4 OpoHia/ieH cunyc 28
1.4. AnaTOMHfl na c-bceflHn oö^aciu 29
1.5. Onanonornfl Ha noca 32
1.5.1. OöoHflHi/ie 33
1.5.2. HocHOflnmaHe 35
1.5.3. Unnnapna 4)yHKMH« na HOCHaia nuraBuqa 36
1.6. npeflBapme^HH nac^eflBaHMfl 37
1.6.1. KnuHi/iHeH npemefl 37
1.6.2. Paflnonorna 38
1.6.3. MnKpo6i/io/iornMHH n a^eprnHHn nscneflBaHiiR 40
1.6.4. PnHOMaHOMerpn« 41
1.6.5. 06oHaTe/iHn lecroBe 42
1.6.5. EHAOCKoncKM wac^eflBaHMR na noca 43
1.6.7. JlnLieBa Mop^oMeipn« 44
1.6.8. OoTOMeTpuMen n Me^a^OMerpMMeH ahanna na
Te/iepeHTreHorpa4)HH 47
1.7. CeriTon/iacTMKa 49
7

1.8. PnHormacTMKa 62
1.8.1. npeflBapme/iHO nnai-inpaHe 62
1.8.1. Mofle/inpaHe Ha Btpxa na noca 64
1.8.2. Mofle/inpaHe na rtpöa Ha noca n jiarepa^HMTe HOCHH
creHM npn KM(j)03a m npn KM4)0CK0Jin03a 68
1.8.4. OiBopeHM TexHUKM npM pMHOcenTon^acTHKa 77
1.8.5. ABTO-M A^OTPANCN^AHTAIN 79
1.9. Heyflann npn pMH0cenT0n^acTMKa 82
1.9.1. nep^opaqnM na cenia/IHHR xpym^n 82
1.9.2. BiopuMna pMHOcenronnacTHKa 84
5M6^Morpa(t)Hfl 87
8

KAMHMHHA M T0n0rPA4>CKA
AHATOMMfl
1.1. EiviöpMOHa^HO pasBMTue Ha Hoca u
OKO/IOHOCHMTe KyXMHM
EMÖpMOHa/iHOTO pasBMTue Ha noca e peay/iraT na MHO-
WECTBO MESENXUMHH NPOMECU, NSRPA^FLAINN NTPBUHHAIA
cioMa. OPOHIANHHAT USPACITK ce ocjjopMa OT npoMMHeHMUFi
Me^fly npoiOMOBtKa m enme^hna noKpus na ycTHaia Kyxn-
na. fl^aKa OT eKTOflepMaTa npes neTi/m BtTpe yTpoöen Meceq
flaBa Hana/IOTO na naTepa^HMTE CTCHM na noca n cmnycHTe.
OT Te3i/i eKTOflepMa/IHM nnaKM BtSHMKBa M on^aKTopHaTa
30Ha B noca. (4)Mr. 1)
Mesenxi/IM-bT naB^uisa OT c"b3flaBau4Ma ce npeMaKci/ma-
pen n3pacT"bK OT flOJiHaTa ycTHa, KaTO cbBflaBa xiaTepanHMTe
Kpi/ma Ha xpyma^naTa nacT na Hoca. OT TyK ce ctsflaBa n Ha-
Man0T0 Ha .qo/inaTa Me/IKXT- ntpsaTa BMcqepa^Ha fl"bra. EK-
TOflepMtT B Tasn 30Ha, FLABAIQ NANANOTO HA BKOCT^BaneTO na
ABeTe nacTM na MaHflnöynaTa m ziaTepariHua n3pacT"bK Ha no­
ca MOflennpaT Hocni/iTe KOCTM M Ha30 -naKpi/iMa/iHaTa ci/icTe-
Ma. OT MaKCunapHMfl i/i3pacT"bK Hpe3 HAFLNRAHE HA BTNUIHUTE
CTeni/i na noca ce oc^opMHT ntpBUHHi/iTe H03flpM. Me3eHxn-
M"bT HaBnn3a npe3 TAX M flaBa HANA^OTO HA npi/IMI/ITI/iBna HOC-
na KyxMha. TA ce OTfle/IA OT NTPBUHNATA ycTa Hpe3 opo -
Ha3a^Ha MeMÖpana. Ta ce Tpanc^opMupa B MOMeHTa Ha
o^opMane na xoannTe KaTO ntpBUHho HeGqe. ToBa e Hana-
/IOTO na oöocoöaBane HA YCTNATA KYXMHA M OTfle^aneTO M OT
noca. na/iaTi/ma/iHi/iaT M3pacTT3K ce o^opMa npe3 mecTaTa
BtTpe yTpoöna ceflMnqa. OT Hero 3anoMBa M M3rpa>KlqaHeTO
na npi/IMI/ITI/iSHi/ia cenTyM. B HanariOTO TOM e M3L|a^o OT xpy-
ma/i. ropnaTa My nacT ocM^MMupa m 4)opMMpa lamina
perpendiculars. Ha no-K-bcen eTan - XI BtTpe yTpoöna cefl-
9

MMMa-ocMcjwMMpa m vomer. KocTHme MeHipoee b ceniyMa
cbLnecTByBai naK flo nyGepieia - eflHO ot ocHOBaHnaia 3a
OTKa3 ot onepaqnM npeflu 15 roflmuHa Bbspaci.
Ot /iaTepa/iHi/iTe cTenn ce cbBflaBaT m kohxhtg b XI BtTpe
yTpoöna ceflMMqa.
AHOMannn
BbBHUKBaT npn BceKM eflMH momcht Ha ne cpacTBane
npM cbSflaBaneTO na noca.TaKa rpeiuKa npn cpacTBaneTO na
MaKCMnapHMH nspacTtK c npeMaKCunaTa boaht flo qenKM b
oönacTTa na ropnaTa ycTna. Pasfle/iaHe npn cnnBaHeTO Ha
MaKCunaTa n naTepannnTe hochm CTenM BOflM flo oöpasysa-
hcto Ha nuqeBM qeriKM c OTBopen naso naKprnvianeH Kanan.
AhOManHM ce HaönKDflaBaT m npi/i He cpacTBaneTO na nanaTM-
HannaTa koct ctc cenTyMa. Haui- MecTi/mT npi^SHaK na Tesn
aHOMa/iMM e uvula bifida. OTHOcnTe/iHO pa^Ka e rrb/maTa
nunca Ha noca, a Hai/i-Te>KKM ca MeflHannuTe nnqeBM qenKM
CBbpsann c nponanc na mostdhhh CTpyKTypn b thx. (flec^eKTu
na ntpBaTa m BTopaTa 6paHxna/iHM
fltrn). MHO>KecTBO enH-
flepMannn KMCTi/i b oönacTTa na noca ce 4)opMMpaT npM HaB-
nuBane Ha ermTe/i b nnHUMTe na cpacTBane. - Haso jiaönanHM,
Ha riMHH^Ta na cpacTBane b MaKcunaTa n moöy/iOMaKCi/map-
hm kmcth b oönacTTa Ha iviaKCM/iaTa ot cpeflMHHaTa nv\uv\9 flo
KyneLLiKi/ia Btö, kohto ce npeflcraB^T b nocneflCTBue KaTO
khctm na MaKCu/iaTa.
OKOTIOHOCHM KyxuHM npeflCTaB/i^BaT eBari/iHaMi/in OT
HocnaTa Kyxuna. flp-bB ce pa3Bi/iBa MaKCMnapnua CMnyc (Vll-X
ceflMuua). flpeflCTaBeH e KaTO ManKa Kyxuna oiqe npM pa>K-
flaneTO. PacTe ctc CKOPOCT OT 2-3 MM. Ha rofli/ma c MBpacTBa-
neTO na cpeflHMa nnqeB OTflen. VBe/ii/NaBa ce npM uspacTBa-
neTO na nocTOflHHMTe btdÖm i/i npM peBOpöuna na a/iBeonap-
naTa KOCT npi/i 3ary6aTa MM.
ETMOMfla/iHMTe K/ieTKn ce ctsflaBaT npes MeTBtpTi/ia b^t-
pe yTpoöen Meceq, KaTO hrko/iko ot tfix ctmecTByBaT oi^e
10

NPM pa>KflaHeTO. BKOCTHBaHeTO HM ce noflnoMara OT OCH^M-
KaqnoHHMTe qeHTpOBe B NTPBUHHUFL ceniyM - B lamina
perpendicularis n flBa B"BB BCCKM eiMOMflaneH /laönpuHT.
OpoHTa/iHme CMHyci/i necTO ce pa3no3HaBaT eiviGpno-
HanHO Kaio npeflHM eiMoufla^HM K/ieiKi/I. Te He ce Ha6/iKD,qa-
Bar npn pa^flaHeio. MsniDnHeHM ca cbc cn0HrM03Ha Maca.
PeHTreHorpa(t)CKM ce no3MTMBi/ipaT c^e^ 6-7 roflMWHa B"b3-
paci H ce PA3BMBATFLO 20 ROFLMIIHA B"b3pacT.
C(})eHOHfla;iHi/mi cunyc ce Ha6nK)flaBa npe3 III B"bTpe yr-
poöen Meceq Kaio eBarnHaiiMfl Ha cc^eno- eiMOMflanHUfl pe-
qecyc. CtmeciByBa npn pa^flaneio c MHOTO Ma^tK pa3Mep,
0, 5x2x2 MM., Kaio napaciBa c Hanpe^Bane Ha B"B3PACTTA
npeflUMHO Ha3alq.
Our. 1
11

1.2. K/iMHMHHa aHaioMMfl Ha Hoca
1.2.1. CeniyM
HOCHI/IHT cenryM e cbcraBeH OT KOCTHa M xpymanHa Haci.
KocTHara Maci e cbciaBeHa OT lamina perpendicularis ossis
ethmoidalis, vomer i/i
flBa KOCTHM Lunna Ha MaKCM^aTa. Xpy-
Ln^/iHaia nacT e npeflCTaBena OT cartilago quadrangularis KaTO
flOCTura narope u nanpefl flo Kpn^aTa na a^apHMTe xpyLi^/iM
OT ^aTepannaTa nocHa CTena. Lamina perpendiculars 4)opMM-
pa ropno npeflnaTa nacT OT KOCTHU^ cenTyM. Vomer nsxo^a
OT FLONNATA cc^eHOHfla^Ha noBtpxHoer, KtfleTO
flBeTe My KpM-
na 4)opMMpaT rostrum. HecTO TyK ce (|)opMMpa ^er/io Ha 4)a-
pi/iHreanHi/iTe KnonneTa na a. maxillaris.
flofiHmqT My p-b6 ce
cbHneHFiBa npes cbeflUHMTeriHO -TtKahHH Bp"b3KM K"bM TaKa
HapeHehMH Hoceh KPTCT. TOM ce (|)opMMpa OT OS maxillae n os
palatinae flpeflHH^T ptö Ha vomer ce cbefli/in^Ba na rope cbc
lamina perpendicularis M naflo/iy M nanpefl ctc cartilago
quadrangularis. SaflHH^T p"b6 e CBOÖOfleH n 4)opMMpa MacT OT
xoaHanm/iFi ptö.
cartilago quadrangularis e pa3no^o>KeH B npefluaTa Tpe-
Ta ua HOCHI/IA cenTyM. Harope TOM KOHTaKTyBa HHTMMHO C
ropHMTe p"b6oBe na ziaTepa/iHi/iTe xpyii^^/in, KaTO cteflHHe-
HI/ieTO e
flocTa SflpaBO. Saeflno Te (j)opMMpaT nacT OT NI/IHMHTA
na HOCHM^ rp"b6 - cbinecTBen e^eMenT npM 4)0pMMpaHeT0 na
HOCHMH npo4)Mn. Toßa M^CTO e n03HaT0 n KaTO npeflen cen-
Ta^en -br-b/i. Ha flony cenTanHM^ xpym^n /ie>Ki/i Btpxy spina
maxillaris. TyK ce onucBaT
flBycTpaHHO KptCTaTM cbeflMHH-
TenHO T"bKaHHM noB/ieKna, BflpaBO 4)MKCMpamM xpym^na KTDM
nofl^e>Kau4aTa KOCT. Hanpefl xpyi^^^-bT ce pasno/iara Me^KFLY
MEFLMA^HUTe KpaneTa Ha a^apHMTe xpyu^a^M, paBflenen OT
t^x c TtKa MeMÖpana. HecTO Ta e oni/iCBaHa KaTO MeMÖpano-
Ben cenTyM, o6o3HaMaBaH KaTO BtTpemeH MeKorbKaHeH
Tpubr-briHMK. 3aeflHO c KpaneTaTa n cbeflnHHTenHO-
T"bKaHHi/iTe BptBKn ce (})opMMpa collumela.
12

Our. 2
SoHaia e OT cbmecißeHO (t)yHKMH0Ha^H0 sHaneHue 3a
HOCHOTO flHLLiaHe. M^CTOTO Ha CBl>p3BaHeTO Ha HOCHMfl xpy-
ctc MaKCM/iaia ce onncBa Kaio
flo/ien cenianeH trbn.
ripocTpaHCTBOTO Me^Kfly cenia^HM« xpym^/i i/i /larepa/iHMTe
Kpuna na a/iapHme xpym^/iM ce onncBa Karo ropen cenia­
neH "brb/l.
OT ctmecTseHO BHaHeHne sa cxaGn/iHOCTia na HOCHa-
xa nperpafla B HacTHOcr M 061140 sa nosum/mra Ha HOCHMA
Bp-bx e CBOTHONIEHMETO ME>KFLY cenra/IHMFL XPYM^I N