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A few patients complained of increased full- rospective review of 200 patients undergoing rhinoplasty and ness of their lateral nasal wall secondary to the graft; however discount 20 mg cialis sublingual with visa erectile dysfunction pills at cvs, reported that 68% of primary rhinoplasty patients and 87% the noted fullness decreased over time secondary to scarring of secondary rhinoplasty patients exhibited lateral crural and decreased edema order 20mg cialis sublingual visa erectile dysfunction bathroom. Sheen20 described mobilization significant improvement in their breathing, with six patients and repositioning of the lateral crura, which he later abandoned noting minor aesthetic fullness in the lateral nasal wall. Gunter and Friedman24 described the the support and strength of the lateral nasal wall; however, alar use of lateral crural strut grafts with or without lateral crural rim grafts are placed in a nonanatomic position and are largely repositioning to address cephalic positioning of the lateral crus limited to the treatment of external nasal valve collapse. Oktem et al25 described repositioning of procedure can be performed via an external or endonasal rhi- the lateral crus with a cartilage Z-plasty technique in which the noplasty approach. A precise pocket along the alar margin is lateral crus on each side is transected and the anterior segment fashioned and an alar rim graft (usually 2 to 3mm wide and 1 attached to the domes is sutured to the caudal aspect of the to 2cm long) is placed within the pocket. No suture is necessary posterior segment, thus repositioning the majority of the lateral if an appropriate pocket is fashioned; however, a suture can be crus and providing more support to the external nasal valve. Similar to normally positioned lateral crura secondary to weakness of the ala rim grafting, Rohrich et al28 performed a retrospective cartilage, which can be congenital, iatrogenic, or secondary to review of 123 patients undergoing alar rim grafting (termed trauma or infection. Multiple surgical techniques have been “alar contour graft”) during a 6-year period and noted that 91% described to bolster support of the lateral crus, thus preventing of patients experienced correction of their alar notching or inspiratory collapse of the external nasal valve. Boahene and Hilger29 retrospec- monly used techniques utilized to bolster the support of the tively reviewed 150 rhinoplasty cases over a 1-year period and external nasal valve and the lateral crus of the lower lateral car- identified 31 cases (21%) in which alar rim grafting was used. In all cases in which alar rim grafting was utilized for internal nasal valve collapse. Alar batten grafts are commonly external nasal valve collapse, there was increased alar support fashioned from septal or conchal cartilage and are placed in an and decreased external nasal valve collapse noted postopera- appropriately sized pocket at the site of maximal collapse of the tively without any complications in the series. Gunter and Friedman24 described the use of lateral 63 patients undergoing placement of alar batten grafts for crural strut grafts placed underneath the lateral crus after dis- either internal or external nasal valve collapse or both. The section of the vestibular skin in patients with weakness or authors noted that 98% of patients noted improvement in their cephalic malpositioning of the lateral crus. A cartilage graft harvested from the ear or septum is placed in an appropriately sized pocket spanning the pyriform aperture and overlapping at least the medial aspect of the lateral crura of the lower lateral cartilages. Cartilage grafts are sutured to the underside of the lower lateral crura of the lower lateral cartilages after elevating the vestibular skin. A graded approach to repairing the technique and advocate the use of this technique for alar con- stenotic nasal vestibule. Lateral crural steal and lateral crural overlay: an objec- The nasal tip is a complex area that has significant implications tive evaluation. Arch Otolaryngol Head Neck Surg 1999; 125: 1365–1370 for functional and aesthetic outcomes following rhinoplasty. Tongue-in-groove technique and septorhinoplasty: A 10-Year Abnormalities of the nasal tip can lead to static or dynamic col- Experience. The tongue-in-groove technique in septorhi- lapse of the external nasal valve, leading to nasal obstruction noplasty. Arch Facial Plast Surg 1999; 1: 246–256, dis- and aesthetic abnormalities, in turn leading to the appearance cussion 257–258 of a boxy, bulbous, ptotic, and/or pinched tip. Septal extension grafts: a method the nasal tip; however, no single technique can be utilized to ofcontrolling tip projection shape. Modified back-to-back autogenous conchal cartilage familiar with multiple techniques to address both functional graft for caudal septal reconstruction: the medial crural extension graft. Arch and aesthetic abnormalities of the nasal tip to achieve optimal Facial Plast Surg 2011; 13: 20–25 outcomes. The two essential elements for planning tip surgery in primary References and secondary rhinoplasty: observation based on review of 100 consecutive patients. Plast Reconstr Surg 1997; 99: 943–952, discus- 1986; 112: 726–728 sion 953–955 [5] Pitanguy I. Cartilage Z plasty on lateral crus for treat- 2001; 107: 264–266 ment of alar cartilage malposition. Applications of the M-arch model in nasal tip refine- of alar rim deformities in rhinoplasty. Alar rim grafting in rhinoplasty: indications, techni- the cantilevered spring model. Arch Facial Plast Surg 2009; 11: 285–289 271 Tip Rhinoplasty 35 Nuances in Tip odification: Specific Applications of Cartilage Splitting in Rhinoplasty Anil R. Shah and Minas Constantinides Division of lower lateral cartilages in rhinoplasty has long been inexperienced rhinoplasty surgeon but is often necessary to maligned for producing unnatural results and unpredictable achieve an acceptable rhinoplasty outcome. The original manifestation of this technique resulted help in analyzing recognition of these specific nasal deformities from the Goldman tip rhinoplasty, stereotyped by the nar- in which cartilage-splitting techniques may improve the ulti- rowed, pinched noses of previous decades. In addition, technical details will be given in recently, use of several modifications of this technique in the order for the reader to produce the achieved results. With proper execution of technique and appropriate selection of patients, lower lateral 35. Goldman originally described his technique in a 1957 land- Typically, in patients with excessively long lateral crura relative mark article. An overly long lateral crus refine and maintain natural nasal tip appearance without the may exist coincidentally or independently from the tension requirement of grafts or implants. Unfortunately, dividing the nose or overly long nasal septum and must be distinguished cartilage without reapproximation often led to tip asymmetries from a ptotic nasal tip. Since this first description, of the relationship between the lower lateral cartilages and newer insight into nasal tip dynamics has broadened the appli- septum. The ptotic nose will not have a downward snarl in cation and use of division of lower lateral cartilages as an appearance and the nasal tip support is often weak. On the Anderson originally described the nasal tripod theory to pro- other hand, in the patient with excess long lateral cruses, the vide a simple explanation of tip dynamics. Surgeons who neglect to address the long legs of the tripod, and the conjoined medial crura and caudal lateral cartilage with appropriate modification will invariably septal attachments correspond to the third leg. Kridel and Konior first described the tech- instance, techniques that augment or lengthen the medial cru- nique of lateral crural overlay. Shortening the medial crura or lateral crura are separated from the underlying vestibular disrupting their septal attachments without reduction of lateral mucosa. Then, precise division of the lateral crus lateral to crural length decreases projection and rotation of the nasal tip. Another technique, Shortening the lateral crura and maintaining or lengthening the described by Adamson and others, is to divide the attachments medial crural segment would be expected to increase rotation. For exam- The authors prefer to use nonabsorbable suture tied away ple, a thick-skinned ptotic nose with long lateral crura and from the vestibular mucosa. Preservation of vestibular mucosa short, weak medial crura may not rotate as expected with lat- is necessary to prevent possible cartilage erosion or infection. Conversely, in a patient with a binding sutures can be placed without difficulty and excess long medial crura and short lateral crura, counter-rotation may bulk is not created in the domal area. Proper nasal analysis allows the surgeon to identify Most patients with excessively long lateral cartilages tend to which area is problematic and the subsequent surgical solution. The exceptions are those with Recognition of variant nasal anatomy can be difficult for the long and convex lateral crura. The overlap of the cartilages may 272 Nuances in Tip Modification reduce convexity of these cartilages in select cases and obviate the need for lateral crural strut placement. There have been a paucity of articles pub- lished describing infratip lobule deformities and their subse- quent management in the scientific literature.

Note the wide variability in doses needed to produce the target response for the 100 subjects discount cialis sublingual 20 mg with mastercard erectile dysfunction when young. Clinical Implications of Interpatient Variability Interpatient variation has four important clinical consequences generic 20mg cialis sublingual visa erectile dysfunction treatment wikipedia. As a provider you should be aware of these implications: • The initial dose of a drug is necessarily an approximation. Conversely, a small (or low or narrow) therapeutic index indicates that a drug is relatively unsafe. The concept of therapeutic index is illustrated by the frequency distribution curves in Fig. The curves for drug Y illustrate a phenomenon that is even more important than the therapeutic index. As you can see, there is overlap between the curve for therapeutic effects and the curve for lethal effects. This overlap tells us that the high doses needed to produce therapeutic effects in some people may be large enough to cause death in others. The message here is that, if a drug is to be truly safe, the highest dose required to produce therapeutic effects must be substantially lower than the lowest dose required to produce death. Drug Interaction Drug-Drug Interactions Drug-drug interactions can occur whenever a patient takes two or more drugs. Some interactions are both intended and desired, as when we combine drugs to treat hypertension. Consequences of Drug-Drug Interactions When two drugs interact, there are three possible outcomes: (1) one drug may intensify the effects of the other, (2) one drug may reduce the effects of the other, or (3) the combination may produce a new response not seen with either drug alone. Intensification of Effects When one drug intensifies, or potentiates, the effects of the other, this type of interaction is often termed potentiative. Increased Therapeutic Effects The interaction between sulbactam and ampicillin represents a beneficial potentiative interaction. When administered alone, ampicillin undergoes rapid inactivation by bacterial enzymes. Increased Adverse Effects The interaction between aspirin and warfarin represents a potentially detrimental potentiative interaction. Both aspirin and warfarin suppress formation of blood clots; aspirin does this through antiplatelet activity, and warfarin does this through anticoagulant activity. As a result, if aspirin and warfarin are taken concurrently, the risk for bleeding is significantly increased. Reduction of Effects Interactions that result in reduced drug effects are often termed inhibitory. As with potentiative interactions, inhibitory interactions can be beneficial or detrimental. Conversely, inhibitory interactions that reduce therapeutic effects are detrimental. Reduced Therapeutic Effects The interaction between propranolol and albuterol represents a detrimental inhibitory interaction. Propranolol, a drug for cardiovascular disorders, can act in the lung to block the effects of albuterol. Reduced Adverse Effects The use of naloxone to treat morphine overdose is an excellent example of a beneficial inhibitory interaction. When administered in excessive dosage, morphine can produce coma, profound respiratory depression, and eventual death. Creation of a Unique Response Rarely, the combination of two drugs produces a new response not seen with either agent alone. When alcohol and disulfiram are combined, a host of unpleasant and dangerous responses can result; however, these effects do not occur when disulfiram or alcohol is used alone. Basic Mechanisms of Drug-Drug Interactions Drugs can interact through four basic mechanisms: (1) direct chemical or physical interaction, (2) pharmacokinetic interaction, (3) pharmacodynamic interaction, and (4) combined toxicity. Direct Chemical or Physical Interactions Some drugs, because of their physical or chemical properties, can undergo direct interaction with other drugs. Frequently, the interaction produces a precipitate; however, direct drug interactions may not always leave visible evidence. Because drugs can interact in solution, it is essential to consider and verify drug incompatibilities when ordering medications. Pharmacokinetic Interactions Drug interactions can affect all four of the basic pharmacokinetic processes. That is, when two drugs are taken together, one may alter the absorption, distribution, metabolism, or excretion of the other. Altered Absorption Drug absorption may be enhanced or reduced by drug interactions. There are several mechanisms by which one drug can alter the absorption of another. For example, when epinephrine is injected together with a local anesthetic, the epinephrine causes local vasoconstriction, thereby reducing regional blood flow and delaying absorption of the anesthetic. Altered Distribution There are two principal mechanisms by which one drug can alter the distribution of another: (1) competition for protein binding and (2) alteration of extracellular pH. When two drugs bind to the same site on plasma albumin, coadministration of those drugs produces competition for binding. As a result, binding of one or both agents is reduced, causing plasma levels of free drug to rise. However, because the newly freed drug usually undergoes rapid elimination, the increase in plasma levels of free drug is rarely sustained or significant unless the patient has liver problems that interfere with drug metabolism or has renal problems that interfere with drug excretion. A drug with the ability to change extracellular pH can alter the distribution of other drugs. For example, if a drug were to increase extracellular pH, that drug would increase the ionization of acidic drugs in extracellular fluids (i. As a result, acidic drugs would be drawn from within cells (where the pH was below that of the extracellular fluid) into the extracellular space. The ability of drugs to alter pH and thereby alter the distribution of other drugs can be put to practical use in the management of poisoning. For example, symptoms of aspirin toxicity can be reduced with sodium bicarbonate, a drug that elevates extracellular pH. By increasing the pH outside cells, bicarbonate causes aspirin to move from intracellular sites into the interstitial fluid and plasma, thereby minimizing injury to cells. Altered Metabolism Altered metabolism is one of the most important—and most complex— mechanisms by which drugs interact. Some drugs increase the metabolism of other drugs, and some drugs decrease the metabolism of other drugs.

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Administration start feed at low rate (25–30mL/hour); if tolerated increase in 25–30mL increments until target rate met 20mg cialis sublingual with visa erectile dysfunction treatment medscape. Parenteral nutrition If enteral feeding is not achieving nutrition targets cialis sublingual 20mg fast delivery importance of being earnest, consider early conver- sion to parenteral feeding. Administration Options are ‘all-in-one’ mixtures with added electrolytes and micro-nutrients or individually tailored pN bags: • some of the energy should come from lipid sources but there is paucity of evidence to suggest any particular lipid formulations. Caution should be applied when other lipid containing infusions are also in use (e. Monitoring Nutritional support needs to be monitored to assess efcacy and detect any complications. Nutritional Support for Adults Oral Nutritional Support, Enteral Tube Feeding and Parenteral Nutrition. Chapter 5 139 Nervous system Delirium 40 Neurological complications of cardiac surgery 44 140 Chapter 5 Nervous system Delirium • Delirium is an acute and fuctuating change in cognition characterized by inattention with either a fuctuating level of consciousness or disorganized thinking. Incidence • Incidence varies depending on the technique used for measurement, the age group assessed and the type of surgery (table 5. Pathophysiology aetiology of delirium is complex and involves the interaction of the risk factors in table 5. Clinical features • Delirium can be hyperactive (restless, agitated, aggressive), hypoactive (withdrawn, quiet, sleepy) or mixed (table 5. In addition, sedation may be required to facilitate imaging and can prolong the course of delirium. Prevention • a number of strategies to prevent neurological complications in cardiac surgery have been proposed (see b Neurological complications of cardiac surgery, p. Care should be taken to: • Provide an appropriately stimulating environment and reorientate as required • Avoid hypoxia • Ensure adequate hydration and avoid constipation • Identify and treat infection • Ensure adequate nutrition • Identify and treat pain • Avoid sleep disturbance • Avoid sensory deprivation by ensuring visual and hearing aids are working • Encourage early mobilization • Review medications and consider side efects. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Stroke • Stroke is the rapid onset of neurological defcit secondary to infarction or haemorrhage and lasting >24 hours. Incidence • Signifcant variation in the reported incidence of perioperative stroke in cardiac surgery. Clinical features • Depend on the location of brain injury and whether the ischemia is regional or global. Investigation • Neuroimaging will confrm the diagnosis of ischaemic or haemorrhagic stroke. Difusion-weighted imaging can detect acute ischemic events related to microemboli. It is more likely to demonstrate multiple lesions in a watershed pattern of distribution than t2 or FlaIr imaging. Prevention • a number of strategies to prevent neurological complications including stroke have been proposed. Use of aortic cannulae with improved fow characteristics and with flters may be benefcial. No evidence to support ph over α-stat management or pulsatile over non-pulsatile fow. Cerebral desaturation has been shown to correlate with neurological impairment but protocolized treatment of desaturations did not improve outcome. If surgically indicated because of prosthetic valve, risk:beneft assessment with surgeon and neurologist. Blood glucose should be maintained 4–mmol/l although no evidence that this improves outcome. Cardiopulmonary bypass management and neurologic out- comes: an evidence-based appraisal of current practices. Biochemical and physiological signs of this response may be found in all post-cardiac surgery patients if one investigates carefully enough; how- ever, it is clinically apparent in only a proportion and problematic in a minor- ity. Practice point Fever, changes in white cell count, and rise in Crp are unreliable signs of infection immediately after cardiac surgery. X-ray changes, sputum production), and culture results should be used in deciding whether to commence antimicrobial therapy in the frst 48 hours postoperatively. Methylene blue inhibits nitric oxide-mediated vasodilation by a number of mechanisms (scavenges nitric oxide, inhibits nitric oxide synthetase and inhibits guanylate cyclase) and may be efective where other pressor agents are failing: Dose regimen for methylene blue In the presence of a good cardiac index, give a bolus of . Methythioninium chloride: pharmacology and clinical applications with special emphasis on nitric oxide mediated vasodilatory shock during cardiopulmonary bypass. Heparin has a high afnity for pF4 and although neither is immunogenic by themselves antibodies are formed to the complexes. It causes transient mild thrombocytopenia immediately within the frst few days of heparin exposure due to platelet aggregation and sequestration. Clinical features Thrombocytopenia • Usually occurs 5–0 days after start of heparin therapy. Diagnosis Diagnosis is based on a combination of clinical signs and antibody detection. Functional assays have a very high specifcity (though still variable sensitivity) but are resource intensive and technically demanding. Furthermore only a subset of antigens detected by these tests is functionally active in terms of platelet activation. Ideally, characterization requires detection with a high sensitivity test and characterization with a functional assay but this is will only be possible in laboratories with a special interest. If the score is 4 or over (intermediate- or high-risk patients) heparin should be discontinued, and antibody assay information sought. However, diagnosis is difcult as only a proportion of patients (5–30%) with antibodies develop thrombocytopenia. Finally antibody detection varies depending on the method used and between laboratories. Warfarin can be started once platelet count is >50 × 09/L under cover of an alternative anticoagulant. In patients without thrombosis the alternative anticoagulant should be continued until the platelet count has recovered to a stable plateau. Chapter 7 157 Haematology Coagulopathies 58 Blood conservation 60 Point-of-care testing 64 158 ChaPter 7 Haematology Coagulopathies Cardiac surgery as a specialty is almost uniquely placed to provoke the development of coagulation abnormalities. Haemorrhage • Subsequent volume and red cell replacement may lead to the development of coagulopathy due to dilution, loss of factors, and loss of platelets. Platelet damage • aside from dilution of platelets on bypass, mechanical damage from roller pumps or adsorption onto the membrane of the oxygenator may occur. Antiplatelet therapy • a signifcant number of cardiac patients are on antiplatelet medication prior to surgery.

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If the saddle deformity involves significant internal lining deficiency or stenosis discount cialis sublingual 20mg with mastercard erectile dysfunction self treatment, auricular composite grafts may need to Fig order 20 mg cialis sublingual mastercard impotence under 40. Normal nasal contour and airway function were restored with placement of an integrated columellar strut/dorsal graft. Allo- The crooked nose deformity and the saddle nose deformity are plastic materials, while potentially restoring appropriate con- two of the most difficult complications of nasal trauma. Man- tour, significantly increase the risk for immediate or delayed agement requires careful analysis and thoughtful surgical plan- infection. By understanding the three-dimensional nasal septal lining: comparison of the constituent layers. Treatment of nasal stenosis due to deflective septum with and with- North Amer 2000; 8: 515–537 out thickeningof the convex side. The correction of deflections of the nasal septum with a minimum North Am 1999; 7: 303–310 of traumatism. Arch Facial Plast Surg 2006; 8: 42–46 127 Management of the Dorsum 16 Aligning the Bony Nasal Vault in Rhinoplasty Anil R. Shah and Minas Constantinides inappropriate to conceptually think of osteotomies as just caus- 16. With a widely divergent spectrum of nasal bony midal frustum has a slant height (h), an overall height (p1), a deformities, use of a single technique will often result in incon- bottom length (Lb) and top length (Lt), and a bottom width sistent results. Similarly, the nasal bones form allows the surgeon to utilize a ratiocinative approach in can be subdivided into an overall height, slant height, dorsal addressing deformities of the upper one third of the nose. The dorsal width is the width created by each nasal bone as it traverses from the midline horizontally, before it 16. The ventral width is the width created Aesthetics by the nasal bone and the nasal process of the maxilla as it tra- verses down to meet the horizontal face of the maxilla. Using Nasal osteotomies are controlled fractures of the nasal bones the pyramidal frustum as a model for nasal bone dynamics, the and/or adjacent maxillary processes. The nasal bones vary in type and location of the osteotomy will vary according to the thickness from person to person. The average thickness along a desired aesthetic goal and underlying geometric proportions of lateral osteotomy track was determined to be 2. Typically The relationship of the nasal bones and the nasolacrimal duct the osteotomy is created in a high-low-high fashion. An approximation of the nasolacri- lates to initially performing the osteotomy high along the pyri- mal canal can be determined by drawing a line from the lacri- form aperture, low along the ascending maxilla, and then high mal fossa to the anterior attachment of the inferior turbinate. For extra wide nasal The distance of the nasolacrimal duct usually lies deep within bones, a low to high osteotomy will cause further narrowing of the maxilla, but its exact depth and course is variable. The osteotomy begins lower along the nasolacrimal duct system has been reported to be injured after pyriform aperture and gently rises to the nasal bones superi- rhinoplasty, most commonly affecting the nasolacrimal sac, orly. Extremely wide nasal bones, especially with a wide supe- beneath the medial canthal ligament, and the ductal ostium in rior component, may benefit with an intermediate osteotomy. The bony width of the bony sidewall of the nose should be ~75% of the distance of a normal alar base on frontal view. Deviations of the nose can be more readily appreciated by drawing a straight line from the midpoint between the brows to the upper lip and central incisors, provided there are no gross facial skeletal asymmetries. If there is facial deviation present, the nose may appear “straighter” if it is in line with the rest of the facial features. Lt, dorsal length; Lb, ventral length; p1, overall height; h, slant height; Wt, dorsal width; Wb, ventral The nasal bones in shape and structure are comparable to a width. The perforated skin site will heal with inconsequential scarring even without suture placement, although there are divergent reports in the literature about this matter. Proponents of perios- teal elevation feel it decreases the amount of postoperative swelling by preventing periosteal tearing and subsequent bleeding. In patients with previous osteotomies or comminuted nasal bones, periosteal elevating can be destabilizing to the underly- ing nasal bones. Kara and colleagues found less ecchymosis and periorbital edema without periosteal undermining in a randomized trial; patients had undermining on one nasal side and no undermining on the remaining half. A gentle fade of the osteotome toward the medial canthus ensures that the osteotome does not travel into the frontal bone and avoids a “rocker deformity. When performing the procedure through an endonasal approach, the surgical path of least resistance is often through an intercartilaginous incision. This sepa- ration is prevented by placing the osteotome through a separate incision superior to the intercartilaginous incision, just at the retracted so that the nasal width is seen along its entire length. An equal portion of nasal bone is removed with a nasal osteo- Becker and associates found that the use of smaller osteo- tome on each side and osteotomies are performed routinely tomes created less intramucosal tearing when comparing after. In some instances, the medial osteotomy will pro- grafting may be needed to close the open roof deformity. Excision of the nasal bones is best performed with an ideal length, “defining osteotomies” can be performed. The soft tissue envelope is ing osteotomies” are lateral osteotomies with either no fracture 129 Management of the Dorsum Fig. Cross-root the separation at the facial width will provide a slight degree of osteotomies mobilize the entire nasal pyramid and allow for nasal narrowing and definition along the nasal bridge. The osteotome path dif- fers from a medial osteotomy in that the osteotomy is performed 16. Cross-root osteotomies should only be used in select situations as improper The crooked nasal bony pyramid requires a cogitative approach usage can lead to dorsal instability and irregularities. Most deviated nasal bones can be straight- ened by osteotomies performed as just discussed. If there is an asymmetric facial width, creating a discrep- ancy in slant height, a unilateral intermediate osteotomy should Overly narrowed nasal bones are typically a result of aggressive be considered. Several studies have demon- the slant height discrepancy is large, the surgeon should con- strated the consequences of narrowed nasal bones on airflow sider excision of the nasal bone to provide a more equivalent and airway obstruction. An alternative maneuver is to rasp the nasal bones may be widened with placement of spreader graft between the asymmetrically to provide better alignment in the slant height. After medial osteotomy, a space is Persistently crooked nasal bones may be caused by the devia- created. Placement of a spreader graft will act as a doorstop, tion at the ethmoid perpendicular plate. If the facial width is too narrow, plate may allow for the deviation to be corrected. This is per- placement of surgical packing may be needed to push the facial formed by placing the osteotome oblique to the line of the devi- width wider. The osteotome then displaces the nasal bony extremely narrowed noses and left in place for periods of up to deviation to the contralateral side with correction of the bony 8 weeks. Jameson and associates warn about the use of this there will be increased nasal obstruction and pressure on the technique in conjunction with dorsal hump removal due to side of the packing or block placement. Short noses improved stability and led to better lateral repositioning and may benefit from extra width in the osteotomy to give a less periosteal and mucosal tearing. When the nasal bones are narrowed, A controversial issue is how wide the surgeon should place the the remainder of the face is wider in relation to the new nose. Each sur- The illusion created is more prominent to the malar eminences geon will have their own personal aesthetic on how much and eyes.

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