| BackgroundFor nearly three decades, boom of domestic aesthetic and plastic surgery has led to a new level of academic and technology development in this field. It has been dissatisfied with the general improvement for people, meanwhile, people use more demanding vision for the results of operations, pursuing perfect appearance personality. It puts forward higher requirements for clinical plastic surgeon. At the same time, a lot of clinical experiences and a rich collection of cases based on the review and inspection that may also be gains and losses and deficiencies in previous work, and plastic surgeon start to question the related surgical procedures and the basic theory in this field. The modern surgeon in our country can not just stop at the duplication of foreign general technical and theoretical research, while it is necessary for people to base on anatomy to understand the characteristics of Chinese people and attach importance to the difference between the national parties and the west in a more scientific spirit and a more rigorous approach. Besides, we should come up with better surgical procedures and the theoretical foundation, in order to built with chinese characteristics of plastic surgery principles, concepts and methods.With the rapid development of a comprehensive rhinoplasty, an increasing trend occurred in nasal osteotomy for wide nasal dorsum in patients. Too broad nasal dorsum gives a feeling of a frog-like appearance. The majority of this deformity is a congenital deformity and a small number is secondary post-traumatic deformities. Broad nasal dorsum affects overall harmony and beauty of the nose. According to measurement, width of nasal dorsum is 24mm-40mm for chinese people. While the wide bony nasal dorsum is foundation for deformity. Depending on the application of the principles of topology, from the oblique view, the first line is from the eyebrows until the nasion and downward to the nasal dorsum. From the positive side, contour line of the nose starts from the superciliary arch, along the nasal bone, nasal cartilage, and the nasal groove, ends the combination of nose and upper lip. Thus, it forms a smooth "S"-shaped curve. From side, nasion, nasal dorsum and tip of the nose connecting the "S"-shaped curve fully display the three-dimensional configuration of the nose. In the nasofrontal triangle area, through regulation of the light, it can access to an "H" shaped curve. The middle position of "H" curve is equivalent to nasion. The curve is composed of the outer contours of the nose under several different light and different location, which is an important criterion to evalue effects of operation. Wide nasal dorsum destroys the front curve of the appearance of the natural flow, which is difficult to bring up beauty.Anatomy is basic science in surgical fields. Any inventions or improvement of clinical experiences in a surgical procedure were repeatedly verified to generate in anatomical specimens. With the advent of the information age, surgical anatomy bring up new demands on the upgrading of computer technology. Thus, digital anatomy emerges and meanwhile, the development of digital technology in surgical system will also be enriched up. The combination between plastic surgery and computer technology, including the design and simulation before operations has experienced a variety of three-dimensional computer-aided measurement. Nasal osteotomy to narrow the wide nasal dorsum should not only correct the deformity in patients with a wide nasal dorsum, but also involves them in cosmetic surgery. Common complications of this operation are excessive bleeding, edema and congestion, ecchymosis, functional nasal obstruction, postoperative poor shape and asymmetry; lacrimal sac device damage leading to overflow tears, "swing" phenomenon, "ladder" phenomenon. It also includes:a wide range of lateral nasal cartilage incomplete fracture, bone skewed and asymmetrical recurrence of nasal bone at the top of disconnect, bone separation, irregular bone nasal dorsum. There are many reasons while the main reason is not to understand the anatomy of the nasal dorsum and its adjacent structures. The topic aims to study the nasal dorsum and its adjacent anatomical and use three-dimensional reconstruction technology to measure the nasolacrimal canal and design simulation operation to better carry out the clinical cut-off to narrow the nasal dorsum and reduce the incidence of complications and provide the new theory.Part one:Applied anatomy research of broad nasal bone reductionObjective:To further deepen the study of applied anatomy of the nasal dorsum and analyze the postoperative complications causes, meanwhile, to better carry out nasal osteotomy and to reduce their reasonable complications and provide anatomical basis for broad nasal dorsum reduction in order to put forward the security line of. nasal osteotomy.Methods:The clinical surgical anatomy of nasal dorsum was studied bilaterally on 10 embalmed cadaveric head specimens. Observed morphological structure of bone nasal dorsum, nasal blood supply, the relationship between nasal dorsum and the medial canthal ligament, the relationship between nasomaxillary groove and nasolacrimal duct, measurement of nasal osteotomy-related anatomy project. Results:Soft tissue of nasal dorsum includes skin, a thin layer of fat, fiber muscle layer, deep fat layer, the periosteum or perichondrium. Bone structure of nasal dorsum includes nasal bone, maxillary nasal protrusion, frontal nasal process. The blood supply of nasal dorsum comes mainly from facial artery and ophthalmic artery. Nasion, nasal dorsum, nasal outer side receive nasal dorsum artery which is the main branch of the ophthalmic artery, lateral nasal artery which is a branch of facial artery, and internal canthus arteries. The external branch of the anterior ethmoid artery which is branch of ophthalmic artery distributed the nasal dorsum.①Nasal bone suture line length:(25.2±2.41)mm。②nasomaxillary suture line length:(29.2±1.24)mm③Frontal process of maxilla thickness:(1)Piriform aperture:(1.86±0.14) mm (2)Inferior orbital rim level:(2.18±0.09) mm (3) Medial canthal ligaments level:(2.78±0.06) mm④The distance between nasomaxillary groove and nasolacrimal duct:(1) Superior:(3.52±0.05) mm (2) Median:(5.10±0.09) mm (3) Inferior:(5.62±0.06) mm⑤The distance from the midpoint of insertion of the anterior branch of the medial canthal ligament to the nasomaxilloric suture:(2.87±0.06) mm.Conclusions:In all osteotomies, a stab incision was made on piriform aperture and only limited periosteal elevation was made to engage the osteotome. Low to high osteotomies were performed. At the most distal point of the osteotomy a small triangular bone was left intact and the nasofacial groove was followed until the inferior orbital rim level was reached about 3.5mm.At this point, the osteotome was directed to nasion. This is a safety osteotomy line.Part two:3D Reconstruction Of Nasolacrimal Duct Anatomical Character In Relation To Nasal OsteotomiesObjective:To investigate the anatomical character of nasolacrimal dust by 3D reconstruction based on the data of 64-row helical computed tomography (CT), and provide anatomical bases for nasal osteotomies.Methods:64-row spiral CT-PHILIPS Brilliance64 scans were taken in 30 adult volunteers heads and using medical image processing software Mimics8.11 and medical image processing software MI-3DVS to study the data. We could measure related radial line of nasolacrimal duct and analyze the site of nasolacrimal duct injury.Results:The length of nasolacrimal duct was (11.50±0.07)mm, the distances between nasolacrimal duct and nasomaxillary groove were(3.57±0.23)mm,(5.08±0.14)mm,(5.63±0.10)mm respectively.The inwall thickness was(1.19±0.08)mm. The angle between nose and face was(127.07°±7.14°).The angles between nasolacrimal duct and vertical plane, horizontal plane and coronal plane were(8.38°±0.51°), (73.41°±3.30°)and(12.32°±1.27°)respectively.Conclusion:The anatomical data of nasolacrimal duct obtained from spiral CT 3D reconstruction have important safe guidance to the therapy of wide nasal dorsum deformity by nasal osteotomies. Bony nasolacrimal duct is from the lacrimal sac fossa to the top of inferior nasal meatus, and route is roughly"八"shape. In the lacrimal sac the shortest distance between nasal lacrimal duct and nasal maxillary groove is (3.57±0.23) mm, and then farther and farther away from nasal maxillary groove, suggesting that lateral nasal osteotomy near the lacrimal sac is easier to damage nasal lacrimal duct and in the beginning of lateral nasal osteotomy it is often far away from the nasolacrimal duct and it will not damage the nasal lacrimal duct. Therefore, the study of the imaging anatomy of nasolacrimal duct characteristics has a guiding role in nasal osteotomy, which can effectively avoid unnecessary damage.Part three:Application of visible simulation surgery in nasal osteotomies for the wide nasal dorsumObjective:Using the original data of 64-row helical computed tomography (CT) scanning, to make three-dimensional reconstruction and visual simulation surgery and evaluate the clinical application of digital medicine in nasal osteotomies for the wide nasal dorsum。Methods:To collect the data of adult volunteers heads on 64-row helical CT scanning, the automatic extraction and segment were carried on to the CT sequence images based on the algorithm of auto adapted region growing. The images which had been segmented were proceeded the 3D reconstruction by medical image proceeding system which was designed by us. Then reconstructed objectives were imported into FreeForm Modeling System in the form of STL format to embellish and smooth. Using the GHOST SDK soft ware of FreeForm Modeling System Various instruments were developed. Investigate the visual simulation surgery of nasal osteotomies with PHAN TOM soft ware.Results:Three-dimensional reconstruction of heads could accurately reflect the size and anatomy of the nose. It could also simulate the nasal osteotomies surgery environment, complete nasal osteotomies with a sense of force-feedback during the whole operation. The visual simulation surgery is high simulated, vivid, exact and give the feeling of'strength' and make people feel operating a real surgery on an operation table.Conclusion:Three-dimensional reconstruction and visible simulation surgery will help the surgeon know the surgery environment of individualized nasal osteotomies, understand the anatomical and spatial structures of the nose and nasolacrinal duct, simulate operating procedure, and compare different surgical programs to improve achievement ratio and reduce surgical complications. Part four:An Explore Of Clinical Application In Nasal Osteotomies For The Wide Nasal DorsumObjective:To use outcomes from applied anatomy of the nasal dorsum and computer analysis of three-dimensional reconstruction, and design more convenient and effective method for medial and lateral nasal osteotomy in order to better prevent or reduce the nasal osteotomy complications. Summarize the experience of repairing wide nasal dorsum deformity through medial osteotomy and lateral osteotomy.Methods:Performing medial osteotomy through internal rhinoplasty approach, then performing lateral osteotomy through pyriform aperture or intraoral approach and along nasomaxillary groove, treat wide nasal dorsum deformity through medial osteotomy and lateral osteotomy.Results:24 patients were managed with this measure, preoperative measurement of the width of nasal dorsum range (32-43) mm, an average of 33.8mm. 7 days after re-measurement of width of nasal dorsum (25-29) mm, an average of 27.2mm. The period of follow-up ranges from 2 months to 10 months, the outcomes were excellent in all 24 cases. The deformity of the nose was corrected satisfactorily and normal nasal shape was obtained.Conclusion:Medial osteotomy combined with lateral osteotomy can efficiently correct wide nasal dorsum, the normal nasal shape can obtained after the operation.
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