NGOAi KHOASODAC BIET 1,2,3/2012
TAO HiNH NANG S O N G M O I SAU CHAN THlAING MUON
BANG CHAT LIEU SILICON
Vu Trung Trirc*, Bui Mai Anh*, Nguyin Hdng Ha*
TOM TAT
Bat van de: Chan thu'dng mui gap trong khoang 50% sd tru'dng hdp chan thu'dng ham mat. 0 Viet Nam cac ton thu'dng mui tren nhu'ng trirdng hdp chan thu'dng ham mat nang van chi/a thiic s i i du'dc quan t a m . Nghien ciiu nay danh gia ket qua tao hinh sdng mui thi hai sau chan thi/dng bang chat lieu Silicon.
BOI t&dng va ph&dng phap nghien c&u:
tren 14 benh nhan cd chan thu'dng ham mat nang da du'dc p h l u thuat ham mat thi dau nhu'ng cdn bien dang sdng mui sau chan thu'dng du'dc tao hinh sdng mui thi hai bang chat lieu Silicon. Phu'dng phap nghien ciTu tien ciTu.
Ket qua: Hau het cac benh nhan deu hai long vdi ket qua sau phau thuat, 2/14 tru'dng hdp phai lay bd chat lieu do can thiep tao hinh qua sdm hoac cac can thiep phau thuat sau khi dat khung Silicon gay Id chat lieu.
Ket luan: Tao hinh cac ton thu'dng sdng miii mudn bang chat lieu Silicon la mdt phau thuat tu'dng ddi an toan, tin cay, thdi gian dieu trj va nam vien ngan.
SUMMARY
Silicon secondary a u g m e n t a t i o n rhinoplasty In p o s t - t r a u m a t i c patients
Introduction: Nasal trauma appears in a half of the maxillofacial injuries. In Vietnam, the nasal lesions in cases of severe maxillofacial injuries has not really been considered. This study preliminarily a^luated the results of the secondary augmentation rhinoplasty folbv^ng injury by Silicon material.
Material and method: on 14 patients with severe maxillofacial injuries who were suffered the primary maxillofacial surgery, but secondary
nasal deformities nose were noted. Reseach method was prospective study.
Resuits: Most patients satisfied with the outcome after surgery. In 2 / 14 cases, the materials were extruded must be removed following early sugical interventions post-trauma or other surgical interventions after placing Silicon.
Conclusions: Silicon secondary augmentation rhinoplasty following injury is reliable, predictable surgery and decreases hospitalization.
I. OAT V A N o f
Chan thuang ham mat la tdn thuong thirdng gap d Viet Nam. Trong sd chan thucmg ham mat cd 50% benh nhan cd chan thuong miii [6]. Theo nghien ciiu ciia mdt sd tac gia nude ngoai, ti Ie xuat hien cac di chung sau chan thircmg miai mac du da dugc phau thuat thi dau van rat cao, tdi 40 - 42%.
Cac di chung nay bao gdm bien dang miii va khuyet hdng mHi. Cac di chimg nay thudng dugc tao hinh thi hai va lira chpn hang dau la chat lieu tu than nhu xuoTig hay sun sudn tu than do it kha nang gay nhiem trimg va dao thai [2]. Tuy nhien khdng phai trudng hgp nao benh nhan ciing chap nhan mot cugc phau thuat ldn va mgt dudng seo d vj tri lay chat lieu ghep, d$c bi?t la vdi b?nh nhan Chau A. Trong nhijng trudng hgp nay su dung chat lieu nhan tao la can thiet [3]. 6 Viet Nam hien nay, da phan tac chan thuang mGi trong benh canh chan thuang ham mat nang chua dugc xu tri thi dau, muc dich chinh ciia phlu thuat ckp cuu la duy tri tinh mang ngudi benh, ket hgp xuong ham mat vi
Khoa phau thuat Tao hinh - Ham mat, Benh vien Viet D&c
405
OAI HO! HOI NGOAI KHOA VN LAN THLT Xll VA HOI NGH! KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV vay cd mdt ti Ie idn benh nhan bien dang mui
sau chan thuang. Phau thuat tao hinh thi hai van chua dugc quan tam diing mirc. Mot van de khd klian ddi vdi phau thuat tao hinh chan thucmg miii thi hai d benh nhan Viet Nam la su khd chap nhan them mdt phau thuat ldn nira sau ldn phau thuat dau tien va md them dudng rach de lay chat lieu ghep. Them vac dd ly do kinh te ciing la van de het sue dugc quan tam.
Chinh vi vay sir dung cac chat lieu tu ben ngoai ca the ddi khi la mdt giai phap hiju hieu.
Nghien cuu nay budc dau danh gia ket qua tao hinh nang sdng mui sau chan thucmg bang chat lieu Silicon.
II. DOI TUONG VA PHUONG PHAP NGHIEN CCfU Thiit ke nghien c&u: nghien cim md ta lam sang tien ciru, tien hanh tai khoa Phau thuat Tao hinh - Ham mat, benh vien Viet Dire.
Doi tirffng nghiin ciru:
Gdm 14 benh nhan: 6 nam va 8 nil.
Tieu chuan lira chdn: nhiing benh nhan cd bien dang sdng mui sau chan thucmg da dugc phau thuat ham mat.
Tieu chuan loai trir; benh nhan cd khuyet hdng miii hoac cd bieu hien khd thd do eac tdn thucmg gay bien dang vach ngan hoac hep dudng thd.
Thdi gian nghien ciiu: tir thang 07 nam 2007 den thang 11 nam 2010, thdi gian theo ddi trung binh la 12 thang.
III. KET QUA
Tren tdng sd 14 benh nhan gdm 8 nii va 6 nam, tudi tir 18 den 40. Nguyen nhan chkn thucmg deu do tai nan giao thdng. 100% sd trudng hgp cd chan thuang ham mat nang da dugc phau thuat ket hgp xuang, sau phau thuat ham mat cac benh nhan nay cd bien dang sdng mui thap nhung khdng cd khuyet hdng mui va khdng cd bieu hien khd thd.
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Phau thuat nang sdng mui dugc tien hanh dudi gay te tai cho qua dudng rach trong lo mai. Sau phlu thuat chi c^n dimg khang sinh chdng nhidra triing va giam dau dudng u6ng.
Hau het benh nhan hai Idng vdi ket qua hinh the mui sau phau thuat. Cd 2 trudng hgp bj lo khung Silicon phai lay bo. mgt trudng hop phlu thuat tao hinh sdm, 3 thang sau 1^
phau thuat trudc dd va trudng hgp thii 2 dugc phau thuat tao hinh lai tru miii sau kh!
dat khung Silicon 2 thang. Nhirng trudng hgp khac (86%) dugc theo ddi sau phau thuat dat khung Silicon vdi thdi gian ngan nhat la 12 thang chua thay xuat hien bien chiing gi, benh nhan hai Idng vdi ket qua phau thuat, khdng cd bieu hien nhiem trung, kich iing da tai chd hay lech veo khung Silicon.
IV. BAN LUAN
Tren cac benh nhan chan thuang ham mat cd chan thucmg sdng miai, cac tac gia Au My thudng tien hanh phhx thuat triet de ket hgp xuong ham mat va chinh miii thi dau.
Cac bien dang miii sau ehan thuang van dugc ghi nhan 6 miic 40%, cac tac gia cung chi ra ba diem quan trgng nhat can tao hinh ddi vol mui sau ehan thucmg la sdng miii, vach ngan va dau miii, nhiing benh nhan cd chan thucmg thap sdng miii thudng dugc tao hinh thi hai bang chat lieu dugc lira chgn hang dau la xuong va sun sudn tu than [2].
O Viet Nam, da sd cac chan thuang sdng mui trong chan thucmg ham mat nang chua dugc xir tri thi dau. Lan phau thuat dau tien nay la phau thuat cap ciiu va muc dich chinh ciia phlu thuat do la ciiru sdng tinh mang ngudi benh [6]. Phau thuat xir tri cac tdn thuang xuong chinh mui thi d4u vip phai khd khan trong cac trudng hgp xucmg bi g£ly vun, han the niia nhung dudng rach da dgc hai ben sdng mui d ngudi chau A dd tilp cgn
NGOAI KHOA SO DAC BIET 1,2,3/2012 6 gay thudng de lai seo tuang ddi ro. Nhimg
ly do phan nan chinh ddi vdi di chiing chan thirong miii sau chan thuong la eae yeu td anh hudng den chiic nang nhu tinh trang mat ngiii do tdn thuong than kinh va khd thd do hep dudng thd, rat it trudng hgp den kham Iai vi thap sdng miii. Hon nfta, trong nhimg benh nhSn thap sdng mui cung cd it ngudi cd nhu cau tao hinh, chi cd nhung benh nhan tre la thuc su cd nhu cau. Tham chi chi mdt sd trong sd hg khdng chap nhan dudng rach da de lay vat lieu tu than va ddng y vdi viec sir dung chat lieu thay the nhu Silicon. Chinh vi vay lua chgn benh nhan de tao hinh nang song mui sau chan thuang bang chat lieu Silicon la rat chat che va khd khan.
Phlu thuat nang sdng miii da trd thanh loai phlu thuat phd bien tren the gidi dac biet la d chau A vdi dac diem hinh thai hgc la s6ng mQi thkp [3,4]. Ch^t lieu tao hinh nang s6ng mui cung dugc nghien ciiu va phat tri8n, tir chkt lieu tu than nhu xuong, sun, can, da den cac chat lieu nhan tao nhu cac dang Silicone, Proplast, Mersilene Mesh, Alloderme. Gore-Tex [1]. Wu va cs thay rang sij dung chat lieu nhan tao cho ti le bien chiing thdp hon d ngudi chau a so vdi ngudi
chau au vi nhiing dac diem giai phlu khac biet [7]. Nhieu nghien cim khac cho thay Silicon la chat lieu duge sir dung phd bien nhat vi hai uu the vugt trdi dd la phan iing vdi CO the thap nhat va de tao hinh khi sii dung. Silicon la mdt hgp chat hda hgc dimg trong cdng nghiep, su phat trien ciia cdng nghe da tao ra loai Silicon cd the cay vao trong CO the eon ngudi va chat lieu nay da dugc su dung rat nhieu trong cac img dung lam day md vdi dd an toan da dugc khang dinh qua nhieu thap ky. Viec su dung Silicon ldng bom vao td chiie trong nhieu nam da de lai nhirng hau qua nang ne vi the ngay nay ngudi ta chi su dung Silicon dang khdi hoac dang gel cd vd bgc ben ngoai de Iam day md trong dd cd iing dung nang sdng mui [1,3,4].
Tuy nhien, sir dung chat lieu Silicon de nang sdng mui tren nhiing benh nhan thap sdng miii sau chan thuang vdi eac dac diem khac biet ve cau tnic giai phau va md benh hgc chua dugc nhieu tac gia quan tam va tdng ket.
Chimg tdi cd 14 trudng hgp da dugc thuc hien vdi chdt lieu nay, nhung ket qua budc dau cho thiy cd thi chip nhan dugc ve do an toan va thim my (Anh 1), 2 trudng hgp cd bien chiing se dugc ban luan ky d phan sau.
I,,/, / \ I 1 thuong ham mat gay xurang ham tren Tir the nghieng trai Hinh anh say phau thu^t 1 nam (traO cho tha\ ton thuong gay thip s6ng mui. Sau phau thuat nang song miji bang chat lieu Silicon 407 3 thSng (phaO benh nhan hai long vai kk qua phlu thuat.
OAI HOI HOI NGOAI KHOA VN LAN THllT Xll VA HOI NGHj KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV
Thdi diem thich hgp nhat de phlu thuat tao hinh miii sau chan thuong da dugc hau bdt cac tac gia thdng nhat la it nhat 6 thang sau lan phlu thuat cudi cung [2,5]. Ly giai cho didu nay, cac tac gia thdng nhat rang, sau khi chd mdt thai gian dai nhu vay cac cau triic giai phau nhu xuong, sun va td chiic lien ket mdi gin trd ve binh thudng, trd nen mem mai sau nhiing tac ddng do chan thuang va phlu thuat. Ddng thdi ciing han che den miic thap nhat kha nang eiia cac nhiem triing tiem tang [2], Chiing tdi cd mdt trudng hgp dugc phlu thuat lan dau vi vet thuang sg nao hd
vimg tran va chin thuang ham mat. Ba thang sau chin thuang benh nhan dugc phau thuat lan hai phdi hgp tao hinh khuyet xuang vimg tran bdi bae si phlu thuat than kinh v^ t^o hinh nang sdng miii bang chat lieu Silicon do bac sT phlu thuat tao hinh dam nhiem. Sau phau thuat 10 ngay, duong rach trong mui khdng lien, chay dich. Id chat Heu va bdt budc chiing tdi lay bd khung Silicon, BlSn chiing nay phan nao chi ra rang viec chd dgi it nhat 6 thang sau Ian phlu thuat cudi cimg trudc khi tien hanh phlu thuat tao hinh mui la can thiet.
Anh 2. Nii 32 tudi, phau thuat sua lai tru miii va dau miii sau khi da d^t khung Silicon va hinh anh Id chat lieu trong Id mui phai.
Hau het cac nghien ciiu deu cho thay bien chirng hay gap nhat khi sir dung Silicon nang sdng mui la veo sdng miii. Cac bien chimg tiep theo la nhilm trung va Id chat lieu [3-5]. Tuy nhien chua cd nghien ciiu nao tien hanh rieng tren cac benh nhan sau chan thuang. Sau it nhat 1 nam theo doi, khdng cd tnrong hgp nao ghi nhan bien chimg lech veo chat lieu trong nghien cim cua chiing tdi.
Trudng hgp bien chirng thii hai trong nghien cim la Id chat lieu nhung khdng phai ngay
sau lln phau thuat dat khung Silicon. Benh nhan nu: 32 tudi, sau phau thuat chan thuang ham mat nang, thap sdng mui dugc ghi nhan khi kham lai. Benh nhin dugc phau thuat nang sdng miii bang chat Heu Silicon 11 thang sau chan thuong, theo doi sau phau thuat 2 thang duong md trong miii lien tot, k8t qua tham my d mirc do chip nhan dugc, khdng nang cao dugc nhieu dau miii vi tinh trang seo co keo sau chan thuong. Benh nhan dugc phlu thuat tao hinh lai tru miii va dau 408
NGOAI KHOASODAC BIET 1,2,3/2012
mui bdi mdt phlu thuat vien khac. Sau lan phlu thuat nay dudng rach trong mui khdng lien, Id chat lieu, benh nhan den kham lai va bat budc ehiing tdi phai liy bd chit Heu (Anh 2). Mac dii chi ed mgt trudng hgp, nhung chiing tdi thay rang sau khi da tao hinh miii bang chat lieu nhan tao tren cac benh nhan sau chan thuong, can can nhac ky nguy co Id chat lieu khi chi dinh va thuc hien cac thu thuat, phau thuat tiep theo cd bdc Id lai chat lieu trong phau thuat. Can cac nghien ciiu vdi s6 lieu Idn hon va thdi gian theo ddi dai hon de khang dinh dieu nay. Nghien ciiu eiia Colin Tham va cs tren nhiing benh nhan khdng cd tien sii chan thucmg thay rang neu nang cao dau miii qua miic gay cang td chirc phin mem sg tang nguy co hoai tii da va niem mac gay 16 chat lieu [3].
V. KET LUAN
Tao hinh nang sdng mQi la phlu thuat phd biSn tren the gidi dac biet la d chau A.
Sii dung chit lieu tu than de lai khuyet hdng va seo noi liy chit lieu, didu nay nhidu khi khd chip nhan ddi vdi benh nhan chau A.
Silicon da ehiing minh dugc tinh an toan khi sii dung tren cac benh nhan thIm my. Nghien cuu nay budc d l u thay rang silicon cd the sir d\mg tren nhiing benh nhan sau chin thuong tirong ddi an toan, kdt qua thlm my chap nhan dugc va cac bidn chiing co the kiem soat.
TAI UEU THAM KHAO
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Homologous Grafts and Allogenic Implants.
Plast, Reconstr. Surg. 125: 99e - 109e, 2010.
2. Christian Vacher, Joao J. Accioli de Vasconcellos, Jonathan A. Britto. The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty. British Joumal of Plastic Surgery 56: 218-223, 2003, 3. Colin Tham, Yung-Lung Lai, Chau-Jin Weng,
Yu-Ray Chen, Silicone Augmentation Rhinoplasty in an Oriental Population. Annals of Plastic Surgery 54: 1-5,2005
4. Dong HJ, Bum RK, Ji YC, Young SR, Hyo JP, Wade WH. Gross and Pathologic Analysis of Long-Term Silicone Implants Inserted into the Human Body for Augmentation Rhinoplasty: 221 Revision Cases. Plast. Reconstr. Surg, 120: 1997,2007.
5. Tae-Bin Won, Hong-Ryul Jin. Revision Rhinoplasty in Asians. Ann Plast Surg 65:
379-384,2010.
6. Vii Trung Trirc. Nhan xet dac diem lam sang va danh gia ket qua phau thuat tao hinh cac ton thuong tang tren mat do chan thuoTig tai benh vien Viet Diic. Lu^n van tot nghiep bac sy ngi trii chuyen nganh phlu thuat tao hinh. Truong Dai hgc Y Ha Ndi, 2006.
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21:176-189, 1992.
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